Microsoft word - patient history form (04-07-11).doc

PATIENT HISTORY FORM FOR ARTHUR F. SMITH, MD NAME: ________________________________________________ AGE: ______ SEX M___ F ___ DATE: _____________ If you are on DIALYSIS, please notify the front desk immediately. (SOME MEDICARE POLICIES ONLY COVER DIALYSIS AND NOT DERMATOLOGY VISITS)

REASON FOR VISIT (MAIN PROBLEMS): CHECK GROWTHS FOR SKIN CANCER NEW GROWTH(S) OLD GROWTH(S) NEW RASH
WORSENING RASH PLEASE FINISH THIS PAGE. PLEASE FILL OUT RASH QUESTIONAIRE (NEXT PAGE) ONLY IF YOU ARE HERE FOR A RASH.
PLEASE EXPLAIN THE REASON FOR YOUR VISIT: ________________________________________________________________________________
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MEDICATION LIST: PLEASE LIST ALL YOUR MEDICATIONS INCLUDING ASPIRIN, VITAMINS, OVER THE COUNTER DRUGS, TOPICAL
MEDICATIONS AND EYEDROPS AND WHAT DISEASE THEY ARE TAKEN FOR. PCP _______________________________________

MEDICATION / PROBLEM BEING TREATED MEDICATION / PROBLEM BEING TREATED
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
___________________________________________________ ___________________________________________________
DO YOU TAKE COUMADIN, PLAVIX, ASPIRIN, VITAMIN E, ST JOHNS WART(CIRCLE)

ALLERGIES and REACTIONS to drugs or topical agents: Penicil in, Keflex, Sulfa, Tetracycline (CIRCLE) or other medications—if so, state which ones:
__________________________________________________________________________________________________________________________
VERY IMPORTANT TO FILL OUT PROBLEMS AND DISEASES: PLEASE CIRCLE ANY OF THE FOLLOWING THAT PERTAINS TO YOU:
Actinic keratoses / squamous cel / basal cell / melanoma / Psoriasis /Seborrheic dermatitis / Eczema / Acne / Contact dermatitis
AIDS Allergies Angina Arthritis (Type:_________) Asthma Artificial heart valves Artificial joints (hips knees) Cancer(Type:_______________)
Diabetes Heart Disease Heart mumur Heart Failure High Cholesterol/TG’s High Blood Pressure Inflammatory Bowel Disease
Hay Fever Hepatitis Kidney Disease Liver Disease Lung Disease Parkinson’s Stroke
Tuberculosis Ulcers Please LIST ALL OTHER MEDICAL ILLNESSES NOT IDENTIFIED ABOVE:________________________________________________________________ ______________________________________________________________________________________________________________________________ REVIEW  OF  SYSTEMS:  DO  YOU  HAVE  NOW,  OR  HAVE  YOU  HAD  DISEASES  OR  CONDITIONS  LISTED  BELOW?  PLEASE  CHECK.   IF  NOT  CIRCLED  ANSWER  IS  NO.  

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PAST MEDICAL, FAMILY, AND SOCIAL HISTORY:
Is there a Family History of any of the following? Melanoma Y/N Basal Cel Carcinoma Y/N Squamous cel carcinoma Y/N Eczema Y/N Psoriasis Y/N
Lupus Y/N Fungus Y/N
SOCIAL HISTORY: Please circle any of the significant exposures Past or Present: Smoking Drinking Occupation Golf Tennis Sports Gardening/Yard work
Beach Boating Swimming Fishing Walking Other
Hobbies:_____________________________________________________________________________________
Please list previous occupations or other significant SUN exposures:_______________________________________________________________________
PATIENT SIGNATURE___________________________________________________PHYSICIAN SIGNATURE____________________________________ PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D RASH QUESTIONAIRE
FOR PATIENTS WITH A RASH ONLY
FILL OUT THIS PAGE ONLY IF YOU HAVE A NEW RASH
Please give information regarding your present RASH OR RASHES: 1____________________________________________________________________________________________________________________________ 2_____________________________________________________________________________________________________________________________ 3_____________________________________________________________________________________________________________________________ PLEASE LIST ALLORAL AND TOPICAL MEDICATIONS AND LOTIONS YOU USED TO TREAT THIS RASH._________________________________ __________________________________________________________________________________________________________________________ 1. Location: (Please circle) scalp face ears neck chest abdomen back genitals groin buttocks legs feet nails hair 2. Duration: (How long have you had this problem?) _____days _____weeks _____months _____years 3. Signs (Does your rash have any: (Please circle) scratch marks/ purple marks/ pus/ blisters/ cracks / thick areas 4. Symptoms/Quality: (Please circle) itch pain burn tender swel ing ulcer other ________________ 5. Related signs and symptoms (Please circle): fever / flu like symptoms/ painful joints (arthralgias)/ sore throat/ none 6. Modifying factors: Medications or treatments that: helped __________________________ aggravated ___________________________________
7. Severity: (Please circle) mild / moderate/ severe 8. Context: Does problem relate to any activity or environmental factors (sun)? No ____Yes (please explain)_________________________________ 9. Timing: Does problem relate to work ,hobbies, housework, cleaning etc.____________________________________________________________ 10. Do you use any of the fol owing: Ponds/ Oil of Olay/ Eucerin/ Vaseline Intensive care/ vitamin E containing products/Neosporin/Bacitracin Triple antibiotic ointment/Topical Benadryl/ Caladryl / Lanacaine / Irish Spring/ Coast/ Safeguard / Lever 2000 Other cosmetics, moisturizers, soaps, toothpastes and anything else being applied to the skin. Everything is important to report.
PATIENT HISTORY FORM (04-07-11).doc 6/25/12 6:00 PM ARTHUR F. SMITH, M.D

Source: http://www.arthurfsmithmd.com/forms/AFSmithDermatology_PatientHistory.pdf