VISIT PREPARATION CHECKLIST

Name :*	Date :
Today’s visit is for :
If we have time, I’d also like to discuss :

In addition to medical and surgical dermatology services, The Medical Spa at Southeastern Dermatology Consultants is available to individuals who desire state of the art aesthetic enhancement. Botox, Restylane, Photofacial, Permanent hair reduction, Spa Facials, and home therapy products are but a few of our offerings.

I am interested in learning about procedures, products, and services that are designed to improve my appearance.

I am interested in a consultation with the Practice’s Licensed Aesthetician.

CURRENT MEDICATIONS (INCLUDE VITAMINS, SUPPLEMENTS, AND OVER THE COUNTER MEDS)

MEDICAL HISTORY: PLEASE CHECK OR FILL IN ALL PHYSICIAN DIAGNOSED MEDICAL CONDITIONS

Skin Cancer:
Melanoma	Date :	Location :
Squamous Cell Carcinoma
Basal Cell Carcinoma
Actinic Keratosis (pre-skin cancer)
Other
Dermatological Disease:
Psoriasis
Eczema
Acne / Rosacea
Blistering Disorder
Healing problems; slow, keloid, bruising
Other
Immunological Disease:
Immune Deficiency
HIV / AIDS
Lupus or Scleroderma
Hematology / Oncology:
Cancer	Type :
Bleeding Problems
Rheumatological Disease:
Osteoarthritis
Rheumatoid Arthritis
Gout
Psychological / Emotional Disease:
Depression
Obsessive – Compulsive
Gastrointestinal Disease:
Crohn’s Disease, Ulcerative Colitis
Esophageal Reflux
Peptic ulcer
Esophagitis
Cardiovascular Disease:
High Blood Pressure
Heart Problems:
Heart Attack;	Date:
Pacemaker / AICD
Irregular heartbeat
High Cholesterol
Endocrine Disease:
Diabetes
Hyperthyroid / Hypothyroid
Neurological Disease:
Stroke / Aneurysm
Seizure / Epilepsy
Alzheimer’s
Fainting
Liver Disease:
Hepatitis;	Type :
Jaundice
Lung Disease:
Asthma
COPD
Tuberculosis
Kidney Disease:
Poorly functioning kidneys
Dialysis	Type :
For Female Patients:
Are you pregnant / Planning Pregnancy
Polycystic ovarian disease
Other / Not Listed:

MEDICATION ALLERGIES

NAME OF MEDICATION	TYPE OF REACTION
	rash difficulty breathing stomach pain/vomiting other:
	rash difficulty breathing stomach pain/vomiting other:
	rash difficulty breathing stomach pain/vomiting other:

SURGERIES

TYPE OF SURGERY	SURGEON	HOSPITAL	DATE

HOSPITALIZATIONS (DO NOT INCLUDE SURGERIES LISTED ABOVE)

REASON	DOCTOR	HOSPITAL	DATE

FAMILY MEDICAL HISTORY (PLEASE ADD ANY OTHERS NOT LISTED)

Conditions/Problems	Family Members affected and exact nature of problems
Melanoma
Cancer
Blistering Disorder
Auto-Immune Disorder
Psoriasis

SOCIAL HISTORY / HABITS

Occupation Retired

Smoker: packs/day Non-smoker Quit smoking in

Smokeless Tobacco:

Alcohol use: Yes (drinks/week: ) No

Recreational Drug use: No Yes

Sunscreen use: Regularly Rarely Never

I have traveled outside the United States in the past three months:

TANNING / SUN EXPOSURE

Do you / Have you had

Always burn, never tan

Usually burn, tan w/ difficulty

Sometimes burn, usually tan

Rarely burn, tan easily

At least 1 blistering sunburn

Utilize a tanning bed

REVIEW OF SYSTEMS: Please mark the symptoms you’ve been having recently.

GENERAL	ALLERGY	PSYCHOLOGY	EYES
weight gain / loss	runny nose	depression	decreased vision
loss of appetite	scratchy throat	high stress level	eye irritation
fever / chills	itchy eyes	suicidal thinking	eye drainage
weakness	sinus congestion	eating disorder	blurry vision
night sweats	sneezing	mental or physical abuse	NEUROLOGY
SKIN	CARDIOLOGY	mood swings	headache
rash	chest pain	obsessive - compulsive tendencies	tingling/numbness
lumps	palpitations	ENDOCRINE	seizures
dry/sensitive skin	leg swelling	excessive sweating	dizziness
hives	MUSCULOSKELETAL	excessive thirst	GASTROENTEROLOGY
suspicious moles	joint stiffness	excessive urination	nausea
suspicious lesions	leg cramps	heat intolerance	vomiting
jaundice	joint pain	cold intolerance	heartburn
acne	joint swelling	BLOOD/LYMPH	abdominal pain
itching	back pain	swollen glands	change in bowel habits
hair loss	neck pain	fatigue	UROLOGY
EAR/NOSE/THROAT	muscle aches	varicose veins	difficulty urinating
congestion	RESPIRATORY	easy bruising	blood in urine
nosebleed	shortness of breath		leaking urine
change in voice	chest tightness
sore throat	cough
difficulty swallowing	wheezing
	congestion

Patient Signature*	Date

(865) 474-8800