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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
Have 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