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New Patient History Form
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Chief Complaint:
Spot
Growth
Lump
Acne
Itching
Rash
Other Please List
History of Present Illness :
Location & Extent
Generalized
List affected areas
Face
Head
Neck
Chest
Back
Breast
Arms
Legs
Hands
Feet
Buttocks
Genitals
Hair
Nails
Eyes
ENT
Axillae
Groin
Other Please List
Duration
Days
Weeks
Months
Years
Unknown
Onset
Sudden
Gradual
Timing
Acute
Chronic
Persistent
Recurrent
Severity
Mild
Moderate
Extensive
Sever
Quality:
None
Itching
Irritating
Painful
Non Healing
Changing
Suspicious
Fear
Bothersome
Upsetting
Unsightly
Anxiety
Other Please List
Aggravated by:
Unknown
None
Stress
Menses
Contact
Allergy
Chemicals
Plants
Work
Sports
Hobbies
Pets
Other Please List
Improved by:
Unknown
None
Medication
Physio
Exercise
Rest
Other Please List
Associated Symptoms :
None
Itching
Weakness
Pain
Abnormal Sensation
Other Please List
Other Problems :
None
Social
Disabilities
Psychological
Need Special Assistance
Other Please List
Current and Past Medical Problems :
Present Skin Diagnosis & Treatment
None
List
Past Skin Diagnosis & Treatment
None
List
Family Skin & Other Problems
None
List
Dermatologist & Physicians seen
None
List
Any other information
None
List
Past, Family & Social History Form
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Current and Past Medical Problems :
None
Psycho
Depression
Memory Loss
Alzheimer
Seizure
Dizziness
Headaches
Stroke
Diabetes
Thyroid
Hormone
Cholesterol
Leprosy
Vision
Glaucoma
Cataract
Hearing
ENT
Mouth
Teeth
Hypertension
Heart Failure
Heart Attack
Arrythmia
Pacemaker
Cancer
Anemia
Bone
Kidney
Urinary
Prostate
Genitals
Arthritis
Lupus
Muscle
TB
Reflux
Ulcer
Celiac
Crohn's
IBD
Hepatitis B
Hepatitis C
HIV or AIDs
Syphilis
Gonorrhea
STD
Herpes
Allergies
Hayfever
Asthma
Radiation
Surgeries
Sick/Weak
Frail
Weight +/-
Staph-MRSA
Disabled
List All
Other Please List
Family History :
None
Acne
Allergies
Eczema
Dermatitis
Psoriasis
Hair Loss
Vitiligo
Atypical
Melanoma
Skin Cancer
Keloids
Thyroid
Arthritis
Diabetes
Lupus
Hypertension
Obesity
Hormone
Glaucoma
Cataract
Cancer
Adopted
Unknown
List All
Other Please List
Social History:
Marital Status
Education
Exercise
No
Yes
Sun Protection
No
Yes
Occupation
No
Yes
Hobbies & Sports
No
Yes
Foreign Travel
No
Yes
Tobacco
No
Yes
Alcohol
No
Yes
Surgery Patients:
Are you taking any Blood Thinners, Aspirin, Steroids and Non-Steroidal anti-inflammatory drugs?
No
Yes
Any reactions to: local anesthetic Lidocaine, Epinephrine, Antiseptics, Baid-Aids, Tapes or list?
No
Yes
Do you have uncontrolled high blood pressure, diabetes, heart problem or poor wound healing?
No
Yes
Do you have Lumpy Scars, Keloids,HIV-AIDS,Hepatitis B,Hepatitis C,TB,or infectious Diseases?
No
Yes
Other Please List
List of Drugs & Other Products Tried :
Please list all your Prescription and Non-Prescription medications including Over-the-Counter drugs, Home Remedies, Street Drugs, Narcotics, Herbal products, Alcohol, Tobacco and/or other agents. Please write down the generic or the brand names of these products
Review Of Systems History Form
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Skin :
None
Acne
Eczema
Spot
Mole
Growth
Rash
Other Please List
General :
None
Itching
Pain
Fever
Headache
Exhaustion
Weight +/-
Other Please List
Allergy :
None
Allergies
Rash
Hives
Vasculitis
Arthritis
Infections
Other Please List
Eyes :
None
Swelling
Irritation
Discoloration
Pain
Itching
Vision Loss
Other Please List
ENT:
None
Hearing Loss
Allergies
Pain
Erosions
Ulcers
Tumor
Other Please List
Cardiovascular :
None
Circulation
Tension
Heart
Varicose
Ulcers
Edema
Other Please List
Respiratory :
None
Breath
Asthma
Allergies
Polyangiitis
Sarcoidosis
Neoplasia
Other Please List
Gastrointestinal :
None
Metabolic
Diabetes
Hepatitis
Gluten
IBD-Colitis
Tumor
Other Please List
Genitourinary :
None
Infection
Bleeding
Pain
Weakness
Rash
Soreness
Other Please List
Neurologic :
None
Testis
Thyroid
Adrenal
Pituitary
Nuroendocrn
Neoplasia
Other Please List
Hemelymphatic :
None
Bruising
Bleeding
Lymph Glnd
Anemia
Cancer
Rash
Other Please List
Psychiatric :
None
OCD-Fobias
Formication
Delusions
Dysmorphism
Neurotic
Factitial
Other Please List
Endocrine :
None
Ovary-Testis
Thyroid
Adrenal
Pituitary
Nuroendocrn
Neoplasia
Other Please List
Please list all your Prescription and Non-Prescription medications including Over-the-Counter drugs, Home Remedies, Street Drugs, Narcotics, Herbal products, Alcohol, Tobacco and/or other agents. Please write down the generic or the brand names of these products
