Drug Allergies & Special Considerations :
Chief Complaint:
History of Present Illness :
Location & Extent
Onset
Timing
Severity
Quality:
Aggravated by:
Improved by:
Associated Symptoms :
Other Problems :
Current and Past Medical Problems :
Present Skin Diagnosis & Treatment
Past Skin Diagnosis & Treatment
Family Skin & Other Problems
Dermatologist & Physicians seen
Family History :
Social History:
Exercise
Sun Protection
Occupation
Hobbies & Sports
Foreign Travel
Tobacco
Alcohol
Surgery Patients:
Are you taking any Blood Thinners, Aspirin, Steroids and Non-Steroidal anti-inflammatory drugs?
Any reactions to: local anesthetic Lidocaine, Epinephrine, Antiseptics, Baid-Aids, Tapes or list?
Do you have uncontrolled high blood pressure, diabetes, heart problem or poor wound healing?
Do you have Lumpy Scars, Keloids,HIV-AIDS,Hepatitis B,Hepatitis C,TB,or infectious Diseases?
Skin :
General :
Allergy :
Eyes :
ENT:
Cardiovascular :
Respiratory :
Gastrointestinal :
Genitourinary :
Neurologic :
Psychiatric :
Hemelymphatic :
Endocrine :
