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Medical History
Name: _______________________________________ Date of Birth: _____-_____-_____ Today’s Date: _____-_____-_____ Who referred you? ___________________________________ Family Doctor: ____________________________________ What type of work do you do? (if retired, what did you do?) ______________________________________________________ Please list any medications you take or use, including eye drops, vitamins, nutritional supplements, herbal remedies, aspirin, and over-the-counter medications: (please use the back of the page if necessary) _____________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Do you take any blood thinners: □ Yes □ No
If yes, which one(s)? □Aspirin (including baby aspirin) □ Coumadin (warfarin) □Plavix □Aggrenox
□NSAIDs (Advil, Ibuprofen, Naproxen, etc) □Other:______________
Do you currently have or recently had: Y N Allergy or sensitivity to latex→ what reaction? ______________________
Y N Intolerance or allergy to dental anesthesia or other numbing medications
Name of Pharmacy: ____________________________________Address: _______________________________________
Do you have any allergies to medications? □ Yes □ No If Yes, please list medication and reaction below. DRUG ALLERGIES REACTION ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ ____________________________________ □hives/rash/itching □swelling □shortness of breath □other:____________ □ I have more allergies than I can list above Review of Systems:
Y N New, changing or worrisome skin spot(s) Medical History: Have you had, or do you have, any of the following?
Y N Autoimmune disease→ type:______________ Y N Cancer→ type:_______________ Have you ever had a blistering sunburn? □ Yes □ No
When you are exposed to the sun, does your skin (choose one):
Surgery History:
Do you take antibiotics before teeth cleaning or surgery? □ Yes □ No
Have you ever had Mohs surgery for a skin cancer?
Family History: Has anyone in your immediate family had any of the following? If yes, please list their relationship to you.
□ My family history is not known to me.
Y N Abnormal moles_________________________
Y N Autoimmune disease ( □lupus □rheumatoid arthritis □thyroid problems □other)________________________
Social History:
Do you use sunscreen? □ Daily □ When outside for any length of time □ Often □ Sometimes □ Never
Do you visit tanning beds? □ Yes □ No
Do you smoke? □ Yes □ No If yes, for how long and how much?:_____________________________________
Do you drink alcohol? □ Yes □ No If yes, how much? _________________________________
(Females Only) Are you pregnant or trying to become pregnant? □ Yes □ No Are you breast feeding? □ Yes □ No
(Females Only) Are you taking birth control pills or using other methods for birth control? □ Yes □ No
If yes, what method(s): □birth control pills □IUD □NuvaRing □Depo Provera □Other:_________________________

Source: http://omahaderm.com/wp-content/uploads/2013/10/med-history-form-Rev-7-9-12-4.pdf