Name
Date
I.
M
EDICAL
I
NFORMATION
Y N
_
_
Diabetes
_
_
Cancer of any sort
_
_
Heart disease or heart problems
_
_
Thyroid, endocrine, or hormonal problems
_
_
Difficulty swallowing or change in your voice
_
_
Eye problems, infections, or injuries
_
_
Nasal problems, difficulty breathing, nose injuries
_
_
Lung problems, pneumonia, TB, asthma, congestion
_
_
Breast problems
_
_
Stomach, intestinal, bowel, hemorrhoid, ulcers, bleeding or digestion problems
_
_
Liver, gallbladder problems
_
_
Kidney, bladder, or urinary problems
_
_
Nervous disorder, depression (explain)
_
_
Epilepsy, convulsions, seizures
_
_
Migraine headaches (explain)
_
_
HIV or AIDS
_
_
Herpes, chancre sores, cold sores, shingles
_
_
ANY infections
_
_
Melanoma, moles, skin cancer, skin disease, skin biopsy
_
_
ANY abnormal lab test or X-ray ever
_
_
EVER hospitalized and why
_
_
DATE of last physical exam, by whom
SURGICAL HISTORY
_
_
List any and all surgeries you have had
_
_
Difficulty or nausea with local or general anesthesia
_
_
Difficulty blood clotting , easy bruising, or heavy menstrual periods
FAMILY HISTORY
_
_
Any cancer in your family. What kind, who?
PERSONAL HISTORY
_
_
Smoking, ever, how much, when
_
_
Recreational drugs
_
_
Alcohol, how much
_
_
Employed, by whom, what position
_
_
Married, marital status, name
ALLERGIES (List any medicines and your reactions):
SKIN HISTORY
_
_
Have you ever used accutane? What year?
_
_
Do you use any topical medications on your skin? What?
_
_
Have you ever had a chemical skin peel?
_
_
Have you ever had electrolysis? Where on your body?
_
_
Do you use wax or depilatories on your face?
