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M. Christine Lee, M.D.
The Skin and Laser Treatment Institute
370 N. Wiget Lane, Suite 125, Walnut Creek, CA 94598 | Get Directions
(925) 500-1180


About Dr. Lee
Dr.Christine Lee
Min-Wei Christine Lee, M.D., M.P.H. is Board-certified as a Diplomate of the American Board of Dermatology and further sub-specialized by completing a distinguished fellowship in Laser Surgery, Cosmetic Surgery, Mohs Micrographic Surgery/Skin Cancer/Facial Plastic Reconstruction, and Advanced Dermatologic Surgery from University of California, San Francisco.

Dermatology Medical History

Please note that it is important to fill in all the fields before submitting. Thank you.

*Name :
*Last name

Mid name

*First name
Reason for today's visit :

Are you allergic to any medications ? YES NO
If yes, list :
1. 2.
Have you ever had dental anesthesia (Novacaine) ? YES NO          Any bad reaction? YES NO
List all medications you are currently taking (including prescriptions, over-the-counter meds., vitamins, and herbals) :
1. 3.
2. 4.

Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO)
Lungs :Yes/No
Bronchitis      
Emphysema      
Asthma      
Chronic Cough      
Morning Cough      
Shortness of Breath      
Wheezing      
Cardiovascular :Yes/No
High Blood Pressure      
Chest Pain      
Heart Attack      
Heart Murmur      
Irregular Heartbeat      
Phlebitis      
   Inflamation of vein      
   Blood clots      
Pacemaker      
Other Systemic :Yes/No
Diabetes      
   Excessive thirst/hunger      
Thyroid      
Kidney      
Bladder      
   Frequency/burning      
Gastrointestinal
   Stomach absorptive disorder      
   Nausea, vomiting, diarrhea
         when taking antibiotics
     
Yeast infection
      when taking antibiotics
     
Arthritis/Joint Deformity      
   Arthralgia      
   Limited motion      
   Artificial joint      
Convulsions, Epilepsy or Seizures      
Fainting      
Infections :Yes/No
Tuberculosis (TB)      

Oral Herpes Simplex      
   (Fever blisters, cold sores)      
Genital Herpes Simplex      
Shingles      

Hepatitis A      
Hepatitis B      
Hepatitis C      

HIV (AIDS)      

Frequent infections      

Skin :
When you are exposed to sun do you : Tan only Tan and burn Burn
Have you ever had skin cancer ? YES NO
Has anyone in your family had skin cancer ? YES NO
If YES, Who?
Do you have a history of any specific skin diseases ? YES NO
If yes, please list :
Do you develop skin rashes in reaction to Medications Food Environment ?
List any other diseases or conditions :
List surgical procedures you have had in the last 6 months :

Social History :
Do you drink alcohol ? YES NO If YES drinks per day
Do you use IV drugs ? YES NO If YES, what ? How much ?
Do you smoke ? YES NO If YES, how much :
Have you had or have you been exposed to HIV (AIDS)? YES NO

Please answer the following questions :
A. Do you bleed easily ? YES NO
B. (Women) Are you pregnant ? YES NO Due Date :
C. What is your occupation ?
D. What are your hobbies ?

Completed by : Patient
*Patient Signature :
Date :