Medical History Form Review of Systems* None Problems with bleeding Problems with healing Problems with scarring (hypertrophic or keloid) Rash Fever or chills Night sweats Unintentional weight loss Blurry vision Sore throat Difficulty swallowing Oral sores Cough Shortness of breath Wheezing Palpitations Chest pain Valvular heart disease History of heart attack/stroke Abdominal pain Bloody stool Diarrhea Constipation Bloody urine Burning on urination Joint aches Muscle weakness Neck stiffness Headaches Seizures Numbness/tingling Depression Photosensitivity Accutane use Immunosuppression/biologic use Immunosuppressive/organ transplant Immunosupprssive/other Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past two years Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedures Rapid heartbeat with epinephrine Latex allergy International travel or contact (please check all that apply to your health conditionAlertsHave you ever had difficulty stopping bleeding?* Yes No Do you require antibiotics prior to a surgical procedure?* Yes No Have you had an artificial joint replacement?* Yes No Do you have an artificial heart valve?* Yes No Do you have a pacemaker?* Yes No Do you have a defibrillator?* Yes No Are you pregnant or currently trying to get pregnant?* Yes No Patient:* Date of Birth:* MM slash DD slash YYYY Today's Date:* MM slash DD slash YYYY Reason for today's visit: Past Medical History* None of these Anxiety disorder Arthritis Asthma Atrial fibrillation BPH-Benign prostatic hyperplasia Cerebrovascular accident COPD Coronary arteriosclerosis Depressive disorder Diabetes mellitus Disease caused by 2019-nCov Elevated blood pressure End-stage renal disease Epilepsy GERD-Gastro Esophageal reflux disease H/O: Hypertension Hearing loss HIV Hypercholesterolemia Hyperthyroidism Hypothroidism Inflammatory disease of liver Leukemia Malignant lymphoma Malignant tumor of lung Malignant tumor of breast Malignant tumor of colon Malignant tumor of prostate Radiation therapy treatment management Transplantation of bone marrow Other (please list): (please check all that apply)Other: Past Surgical History* None Abdominoperineal resection Bilateral replacement of knee joints Biopsy of breast Biopsy of prostate Coronary artery bypass graft Entire transplanted kidney Excision of basal cell carcinoma Excision of melanoma Excision of squamous cell carcinoma H/O: Colostomy H/O: tubal ligation History of apprendectomy History of bilateral mastectomy History of cholecystectomy History of colectomy History of liver excision History of percutaneous transluminal coronary angioplasty History of tissue graft heart valve replacement History of total cystectomy History of transurethral prostatectomy Hysterectomy Kidney biopsy Low anterior resection of rectum Lumpectomy of breast Lumpectomy of left breast Lumpectomy of right breast Mastectomy of left breast Mastectomy of right breast Mechanical heart valve replacement Oophorectomy Pancreatectomy Percutaneous extraction of kidney stone with fragmentation procedure Portosystemic shunt opertation Prostatectomy Prosthetic arthroplasty of bilateral hips Splenectomy Surgical biopsy of skin Total nephrectomy Total orchidectomy Total replacement of left hip joint Total replacement of left knee joint Total replacement of right hip joint Total replacement of right knee joint Transplantation of heart Transplantation of liver Other (please list): (please check all that apply)Other: Skin Disease History* None Acne Actinic Keratosis Asteatosis cutis Basal cell carcinoma of skin Contact dermatitis due to poison ivy Dysplastic nevus of skin Eczema H/O: Asthma H/O: Hay fever Malignant Melanoma Pruritis of scalp Psoriasis Squamous cell carinoma Sunburn of second degreee Other (please list): (Please check all that apply)Other: Have you received a pneumonia vaccination?* Yes No Advance Care PlanningDo you have a health care proxy in the event you are unable to make your own medical decision?* Yes No Designee's Name First Last Designee's Phone NumberDo you have a living will?* Yes No Which statement best reflects your wishes on advanced care recommendations?* Do Not Intubate: I do not wish to have a breathing tube, even if it is necessary to save my life. Do Not Resuscitate: If my heart were to stop, I do not wish to have chest compressions or an automated external defibrillator to restart my heart, even it it's necessary to save my life. Full Cardiopulmonary Resuscitation: I want full cardiopulmonary resuscitation efforts to be made. Skin ProtectionDo you wear Sunscreen? Yes No If YES, what SPF? Do you tan in a tanning salon? Yes No Family History of MelanomaDo you have a family history of melanoma?* Yes No If YES, check all that apply:* Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandfather Grandmother Grandson Granddaughter Medications(prescriptions, over-the-counter meds, vitamins and herbals)Do you currently take any medications?* Yes No 1. 2. 3. 4. 5. 6. 7. 8. Medical Allergies* Check here if none 1. 2. 3. 4. 5. 6. Social HistoryWhat is your smoking status?* Unspecified Unknown if ever smoked Current everyday smoker Current some day smoker (tobacco) Current some day smoker (cigarette) Former smoker Never smoker Smoker, current status unknown Cigar smoker Heavy tobacco smoker Light tobacco smoker Alcohol and Drug UseHow many times in the past year have you had 5 or more drinks in a day for me, or 4 or more drinks in a day for women, or any for adults over 65?* Do you consume alcohol (EtOH or grain alcohol)?* EtOH none EtOH less than 1 drink per day EtOH 1-2 drinks per day EtOH 3 or more drinks per day Illicit drug use? YES NO VaccinationsAre your vaccinations current?* YES NO For patients age 65 or older, have you had a pneumonia vaccination?* YES NO Δ
Aspen Dermatology & AestheticsAspen Dermatology & Aesthetics