Carolina skin care, p
Carolina Skin Care, P.A.
(In relation to your visit today)
Allergies: Any non medication allergies, history of hives, itching, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Cardiovascular: Any problems with your heart such as palpitations, murmurs, irregular pulse, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Ears/nose/throat: Any problems in these areas such as vertigo, nasal drainage, mouth sores, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Eyes: Any eye discharge, itching, blurred vision, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Gastrointestinal: Any problems with stomach/intestines/gallbladder, abdominal swelling, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Hematology/Lymphatic: Any history of anemia, easy bruising, enlarged lymph nodes, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Integument: Any history of skin diseases, moles changes, hair loss, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Musculoskeletal: Any bone/joint/muscle pain, joint swelling, joint stiffness, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Respiratory: Any breathing problems such as wheezing, shortness of breath, chronic cough, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
Psychiatric: History of any mental illness/treatment such as depression, bipolar disorder, etc.
□No □Yes explain ___________________________________________________________________
__________________________________________________________________________________
CONTINUED ON REVERSE
Carolina Skin Care, P.A.
Name ______________________________ Today’s Date _____________
Date of Birth ____________________ Referring Physician___________________
Why are we seeing you today?________________________________________________________
Are you allergic to any of the following:
Have you had any of the following:
□ NSAID’s (aspirin, Motrin, Tylenol)
□ Hepatitis (type) ____________________
□ Other ________________________________
Skin Cancer & Location:
Reaction:
____________________________
□ Squamous Cell ________________________
____________________________
□ Melanoma ____________________________
____________________________
____________________________
For women: Are you pregnant or do you think you may
be pregnant? □ yes □ no
Are you nursing? □ yes □ no
Hav
e you had any surgeries:
Has anyone in your family had:
(please indicate relationship to you)
□ Basal Cell Carcinoma___________________
□ Lupus or other auto-immune D/O______________
□ Heart surgery (type) _______________________
□ Other ________________________________
□ Psoriasis/Psoriasis Arthritis________________
If so, what year was the procedure performed:
□ Squamous Cell Carcinoma__________________
Do you use or have a history of: (If so, when and how
Please list all current medications and dosage:
________________________________________
________________________________________
________________________________________
□ Illegal drug Use (type)________________
________________________________________
□ Tanning bed/sunbathing_____________________
________________________________________
□ Sexually transmitted disease (type)_______________
________________________________________
________________________________________
□ Other_________________________________
Preferred Pharmacy:_______________________
____________________________
Primary Care Physician:_________________________
Source: http://www.carolinaskincare.com/docs/Patient%20History.pdf
Das Noonan-Syndrom Gregor Schlüter1, Malte Rossius1, Armin Wessel2, Barbara Zoll1 Zusammenfassung tyrosin-Phosphorylase, die eine zentrale Regu- that are set low and rotated posteriorly, steno- latorfunktion in fast allen Signaltransduktions- sis of the pulmonal valve and short stature. Das Noonan-Syndrom ist ein Dysmorphie-Syn- wegen von Wachstumsfaktoren ausübt. Diese
Five hot foods that help you keep your cool As the hot weather bears down on us, we look for any way to cool off – heading to the beach, the mountains or the great indoors to escape the sun’s rays. 04 November 2011 | By Luigi Gratton, Vice President of Medical Affairs at Herbalife, International We tend to eat differently when the weather is warm, too - steering clear o