Microsoft word - patient history form (04-07-11).doc
PATIENT HISTORY FORM FOR ARTHUR F. SMITH, MD NAME: ________________________________________________
AGE: ______ SEX M___ F ___ DATE: _____________
If you are on DIALYSIS, please notify the front desk immediately. (SOME MEDICARE POLICIES ONLY COVER DIALYSIS AND NOT DERMATOLOGY VISITS) REASON FOR VISIT (MAIN PROBLEMS): CHECK GROWTHS FOR SKIN CANCER NEW GROWTH(S) OLD GROWTH(S) NEW RASH WORSENING RASH PLEASE FINISH THIS PAGE. PLEASE FILL OUT RASH QUESTIONAIRE (NEXT PAGE) ONLY IF YOU ARE HERE FOR A RASH. PLEASE EXPLAIN THE REASON FOR YOUR VISIT: ________________________________________________________________________________ ____________________________________________________________________________________________________________________________ MEDICATION LIST: PLEASE LIST ALL YOUR MEDICATIONS INCLUDING ASPIRIN, VITAMINS, OVER THE COUNTER DRUGS, TOPICAL MEDICATIONS AND EYEDROPS AND WHAT DISEASE THEY ARE TAKEN FOR. PCP _______________________________________
MEDICATION / PROBLEM BEING TREATED MEDICATION / PROBLEM BEING TREATED ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ DO YOU TAKE COUMADIN, PLAVIX, ASPIRIN, VITAMIN E, ST JOHNS WART(CIRCLE)
ALLERGIES and REACTIONS to drugs or topical agents: Penicil in, Keflex, Sulfa, Tetracycline (CIRCLE) or other medications—if so, state which ones:
__________________________________________________________________________________________________________________________ VERY IMPORTANT TO FILL OUT PROBLEMS AND DISEASES: PLEASE CIRCLE ANY OF THE FOLLOWING THAT PERTAINS TO YOU: Actinic keratoses / squamous cel / basal cell / melanoma / Psoriasis /Seborrheic dermatitis / Eczema / Acne / Contact dermatitis AIDS Allergies Angina Arthritis (Type:_________) Asthma Artificial heart valves Artificial joints (hips knees) Cancer(Type:_______________) Diabetes Heart Disease Heart mumur Heart Failure High Cholesterol/TG’s High Blood Pressure Inflammatory Bowel Disease Hay Fever Hepatitis Kidney Disease Liver Disease Lung Disease Parkinson’s Stroke
Tuberculosis Ulcers Please LIST ALL OTHER MEDICAL ILLNESSES NOT IDENTIFIED ABOVE:________________________________________________________________ ______________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS: DO YOU HAVE NOW, OR HAVE YOU HAD DISEASES OR CONDITIONS LISTED BELOW? PLEASE CHECK. IF NOT CIRCLED ANSWER IS NO.
_______________________________________________________________________________________________________________________ PAST MEDICAL, FAMILY, AND SOCIAL HISTORY: Is there a Family History of any of the following? Melanoma Y/N Basal Cel Carcinoma Y/N Squamous cel carcinoma Y/N Eczema Y/N Psoriasis Y/N
Lupus Y/N Fungus Y/N SOCIAL HISTORY: Please circle any of the significant exposures Past or Present: Smoking Drinking Occupation Golf Tennis Sports Gardening/Yard work Beach Boating Swimming Fishing Walking Other Hobbies:_____________________________________________________________________________________ Please list previous occupations or other significant SUN exposures:_______________________________________________________________________
PATIENT SIGNATURE___________________________________________________PHYSICIAN SIGNATURE____________________________________ PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D
RASH QUESTIONAIRE FOR PATIENTS WITH A RASH ONLY FILL OUT THIS PAGE ONLY IF YOU HAVE A NEW RASH
Please give information regarding your present RASH OR RASHES:
1____________________________________________________________________________________________________________________________
2_____________________________________________________________________________________________________________________________
3_____________________________________________________________________________________________________________________________
PLEASE LIST ALLORAL AND TOPICAL MEDICATIONS AND LOTIONS YOU USED TO TREAT THIS RASH._________________________________
__________________________________________________________________________________________________________________________
1. Location: (Please circle) scalp face ears neck chest abdomen back genitals groin buttocks legs feet nails hair
2. Duration: (How long have you had this problem?) _____days _____weeks _____months _____years
3. Signs (Does your rash have any: (Please circle) scratch marks/ purple marks/ pus/ blisters/ cracks / thick areas
4. Symptoms/Quality: (Please circle) itch pain burn tender swel ing ulcer other ________________
5. Related signs and symptoms (Please circle): fever / flu like symptoms/ painful joints (arthralgias)/ sore throat/ none
6. Modifying factors: Medications or treatments that: helped __________________________ aggravated ___________________________________
7. Severity: (Please circle) mild / moderate/ severe
8. Context: Does problem relate to any activity or environmental factors (sun)? No ____Yes (please explain)_________________________________
9. Timing: Does problem relate to work ,hobbies, housework, cleaning etc.____________________________________________________________
10. Do you use any of the fol owing: Ponds/ Oil of Olay/ Eucerin/ Vaseline Intensive care/ vitamin E containing products/Neosporin/Bacitracin
Triple antibiotic ointment/Topical Benadryl/ Caladryl / Lanacaine / Irish Spring/ Coast/ Safeguard / Lever 2000
Other cosmetics, moisturizers, soaps, toothpastes and anything else being applied to the skin. Everything is important to report.
PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D
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