Dermatologist Englewood - About Skin Derm Header

Health History

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*Patient name :
 *First name

 Mid name

 *Last name
Patient History
Skin Cancer : Yes   No Type :  
Basal cell carcinoma Squamous cell carcinoma
Malignant melanoma
Other types of skin cancer : Yes   No Type :
History heart problems : Yes   No Artificial heart valve      Heart murmur      Pacemaker
Defibrillator
Bleeding disorders : Yes   No Type :
History of blood transfusions : Yes   No
High blood pressure : Yes   No
Arthritis : Yes   No
Artificial joints : Yes   No Type :
Neurological disease : Yes   No Type :
Headaches : Yes   No Type :
Psychiatric history :
Depression :
Yes   No Other :
Auto-immune disease : Yes   No Type : Lupus   Rheumatoid arthritis
Eye disease : Yes   No Type : Glaucoma   Cataracts
Seasonal allergies : Yes   No
Endocrine disease : Yes   No Type : Diabetes   Thyroid problem
Have you ever had X-ray treatment for acne ? Yes   No
HIV/AIDS : Yes   No
Liver disease : Yes   No Type : Hepatitis B Yes  No / Hepatitis C Yes  No
Family history of skin cancer : Yes   No Type :
Family history of medical problems : Yes   No Type :
Social history : Yes   No Smoke :
Alcohol :
Yes   packs per day     No
Yes   drinks per week No
Sexually transmittied disease : Yes   No Type :
Illicit drugs : Yes   No Type :
Other medical problems : Yes   No Type :
Surgical history : List :
History of accidents in last 5 years : List :
Hospitalizations in last 5 years : List :
Medication allergies : Yes   No List :
List medications currently taking :
Have you previously taken antibiotics prior to dental cleanings/procedures : Yes   No
WOMEN ONLY : OB/GYN Breast Feeding : YesNo   Pregnant : YesNo   Planning Pregnancy : YesNo

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Date :