Transcript Health History Form

REVIEW OF SYSTEMS & MEDICATION SHEET
Patient::__________________________________________ DOB:_______________________
Have you ever had skin cancer?
What kind?
 Basal Cell
 I don’t know  Squamous Cell
 Melanoma
 Other Type:
Has your parent, sibling, grandparent or child ever had melanoma?
 I don’t know
Have you ever had asthma?
 I don’t know
Have you ever had seasonal allergies or hayfever?
 I don’t know
Has anyone in your family had eczema?
 I don’t know
Has anyone in your family had asthma, seasonal allergies or hayfever?
 I don’t know
Do you now use or have you ever regularly used tobacco?
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
Have you ever had hepatitis?
 I don’t know
Do you now have or have you ever had high blood pressure (hypertension)?
 I don’t know
Do you have a pacemaker or defibrillator?
No
Yes
No
Yes
No
Yes
Do you have any joint replacements for which you need to take antibiotics for surgery?
No
Yes
Are you pregnant or breastfeeding?
No
Yes
Do you have trouble healing?
No
Yes
Do you tend to bleed excessively?
No
Yes
Do you have a tendency to form hypertrophic (enlarged) scars or keloids?
No
Yes
Do you get an allergic reaction to bandages, bandaids, or antibiotic ointments?
No
Yes
Do you have difficulty with oral antibiotics (e.g. nausea, diarrhea, yeast infections)?
No
Yes
Have you been having headaches and/or dizziness?
No
Yes
What other significant medical problems do you have (things like diabetes, heart disease, etc.)?
 None
To what medications are you allergic?  None
What medications do you currently take? (we only
need names, not the dose or schedule)  None
Are you allergic to latex?  Yes  No
How would you like to be addressed by the nurse when called in from the reception area ? ____________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________