Dermalase patient medical history
Patient Medical History
Patient’s Name:________________________________________ _Date of Birth:_________________ Email:____________________________ Address:______________________________________________ City:____________________________ State:_________ Zip:_______________
Best Phone Number to Reach You:_____________________________ Alternative Phone Number:_________________________________
Employer:________________________________________ Occupation:______________________________ Work Phone:___________________ Person to contact in an emergency:___________________________________________________________________________________________ (Name, Address, and Phone #)
How did you hear about us?_____________________________________________________________________________________
Reason for consultation:___________________________________________________________________________________________________ Are you currently under a physician’s care?________ Specify:_____________________________________________________________________
HAVE YOU EVER BEEN DIAGNOSED WITH:
DO YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING CONDITIONS:
Are you using any eye drops or other ocular medications?
Have you ever experienced hyperpigmentation from an injury?
Are you currently taking aspirin or ibuprofen?
List all medications you are currently taking (including Retin A, Glycolic Acid, and Accutane):
List any drug, makeup, skin, or food allergies (i.e., soaps/cleansing creams):____________________________________________________
Does your medication prohibit exposure to sun or light? __________________________________________
Fitzpatrick Skin Test: Please
Have you been on Accutane in the last 9 months_________ Laser resurfacing in the last year? ___________ circle one of the following that
describes your skin type:
Are you pregnant? ______ If so, how long? _____________________________________________________
Have you ever been tested for HIV_______ Results? _____________________________________________ Red or light blonde hair, light eyes.
Are you prone to herpes breakouts or cold sores? ________________________________________________
What is you natural hair color? __________________________ currently, your hair is (natural / colored)
Have you recently undergone a skin peel or microdermabrasion? ______________________________________ ____________
Is your present skin condition normal or abnormal? ______________________ Oily or Dry? ______________ tans. Also known as “Olive”
When did you last tan your skin? _____________________ Sun, tanning booth, or creams? ____________ ___
When was your last eye exam: / / : – Examining Physician: ____________________________ always tans. Also known as “Olive”
Going back three generations, what is your ethnic background? ________________________________________
Presented at the American College of Gastroenterology 2009 Annual Scientific Meeting and Postgraduate Course. October 23-28, 2009; San Diego, CA. Nitazoxanide and Sucralfate for the Treatment of Helicobacter pylori Infection Purpose: In the United States the incidence of Helicobater pylori (HP) infection has been estimated to be as high as 40% of the general population. While most i
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