mitchellderm.com - medical information

Mitchell Dermatology Medical Information
Patient Name*

First NameLast Name
Age*
Occupation*
Reason for your visit today*
Marital Status*
Pharmacy Name*
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Location *
Do you take current medications*

YesNo
If "Yes" List current medications*
Do you have Current Allergies to medication?*

YesNo
If "Yes" List Current Allergies *
Do you occasionally use
Motrin/other NSAIDS*

YesNo
Aspirin/ Blood Thinners*

YesNo
Birth Control*

YesNo
Itching Pills*

YesNo
Allergy Pills*

YesNo
Social History
Pregnant*

YesNo
Nursing*

YesNo
Do you smoke cigarettes*

YesNo
Have you ever smoked*

YesNo
Do you use alcohol*

YesNo
How Frequently*
Do you have Major medical problems?*

YesNo
If "Yes" List Major medical problems*
Do you have Recent Surgery or Illness?*

YesNo
List Recent Surgery / Illness*
Do you have any of these conditions (Select all that apply)*

AsthmaDiabetesHigh Blood PressureDepressionHypothyroidBleeding TendenciesAIDS / HIVPacemakerArtificial Valve/ JointHepatitisLung DiseaseAcid RefluxLow Blood PressureAnxietyHyperthyroidMigrainesStomach UlcersChrohn’s DiseaseIrritable bowel SyndromeSeasonal AllergiesNone
Do you have any other current skin concerns: (i.e sun spots, skin tags, Wrinkles)*

YesNo
If Yes please explain:*
Skin Cancer History
Have you ever had a mole removed?*

YesNo
If Yes diagnosis*
Have you ever had skin cancer?*

YesNo
Diagnosis*
If yes, type*

Basal Cell CarcinomaSquamous Cell CarcinomaMelanomaNone
Do you use a sunscreen?*

YesNo
Type?*
(currently use)
SPF*
Do you use a tanning bed*

YesNo
Do you lay out in the sun*

YesNo
Have you ever sunburned*

YesNo
Do you have any of the following*

Abnormal MolesDry SkinEczemaItchy SkinRashScarsCold soresAcneSensitive skinHivesPsoriasisRosaceaSores that won’t healRednessNone
Do you have an interest in the following*

BotoxDysportRestylaneMicroneedlingJuvedermVolumaRadiesseCoolsculptingChemical PeelsAnti-aging treatmentsNoneOther
Family History
Has any family member had skin cancer or melanoma?*

YesNo
Who?*
Has any family member had eczema or psoriasis?*

YesNo
Who?*
Please list all skin care products you*
Patient Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
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Mitchell Dermatology Medical Information

Do you occasionally use

Social History

Skin Cancer History

Family History