orange dermatology associates, p.c. · 2018-06-08 · (side 2) your personal past or present...

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ORANGE DERMATOLOGY ASSOCIATES, P.C. (Side 1) MEDICAL HISTORY NAME:_____________________________________________ DOB:____________ Today’s Date:___/___/___ CURRENT PROBLEM (HPI): 1. Reason for visit (circle) (rash, growths, skin cancer check, other)______________________________________ 2. How long have you had this problem?_______________________ YES NO 3. Where is your problem located? (circle) Scalp, ears, eyelids, face, neck, chest, back, arms, underarms, hands, fingers, stomach, groin, thighs, legs, feet, toes, hair, nails, mouth 4. Does the problem (circle) itch, burn, hurt, bleed, ooze, other?_________________________ 5. Has a doctor given you anything in the past to put on or take by mouth for your present skin problem? If yes, please list: __________________________________________________________________________ 6. Have you put anything else on the skin yourself? If yes, please list: __________________________________________________________________________ MEDICATIONS: (Oral or Topical) a) Are you currently taking ANY medications by MOUTH (including prescriptions, hormones, birth control pills, over-the-counter supplements, vitamins and herbals) or suppositories, eye drops, ear drops; or putting anything on your skin? b) If yes, please list: ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ALLERGIES: (Oral or Topical medications) Please specify (e.g. rash, hives, itching, etc.) Medication:_______________________________ Reaction: ____________________________ Medication:_______________________________ Reaction:____________________________ Medication:_______________________________ Reaction:____________________________ SOCIAL HISTORY: YES NO UNKNOWN What is your Occupation? Have you ever smoked? _________________________________ Do you smoke every day? Do you smoke sometimes? Hobbies? Do you still smoke? _________________________________ Do you drink alcohol regularly? ____________________________________ Have you had or been exposed to HIV (AIDS)? YOUR PERSONAL FAMILY HISTORY: Indicate relationship PAST OR PRESENT SKIN CONDITIONS: YES NO (If grandmother or grandfather, INDICATE which one, Skin cancer Type_____________________ and ALSO add (m) for maternal or (p) for paternal) Psoriasis YES NO Eczema Skin cancer _____________________________ Other skin condition Please list: Psoriasis _____________________________ ____________________________________ Eczema _____________________________ Asthma Asthma _____________________________ Hay Fever Hay Fever _____________________________ Problems healing Any other family skin condition? Please list: Thick or elevated scars after surgery ________________________________________________ Bleed easily ________________________________________________ (PLEASE COMPLETE BOTH SIDES)

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Page 1: ORANGE DERMATOLOGY ASSOCIATES, P.C. · 2018-06-08 · (Side 2) YOUR PERSONAL PAST OR PRESENT MEDICAL HISTORY YES NO YES NO High Blood Pressure ’ ’ Colitis/Inflammatory Bowel Disease

ORANGE DERMATOLOGY ASSOCIATES, P.C.

(Side 1) MEDICAL HISTORY

NAME:_____________________________________________ DOB:____________ Today’s Date:___/___/___

CURRENT PROBLEM (HPI): 1. Reason for visit (circle) (rash, growths, skin cancer check, other)______________________________________ 2. How long have you had this problem?_______________________ YES NO 3. Where is your problem located? (circle) Scalp, ears, eyelids, face, neck, chest, back, arms, � � underarms, hands, fingers, stomach, groin, thighs, legs, feet, toes, hair, nails, mouth 4. Does the problem (circle) itch, burn, hurt, bleed, ooze, other?_________________________ � � 5. Has a doctor given you anything in the past to put on or take by mouth for your present skin problem? If yes, please list: � � __________________________________________________________________________ 6. Have you put anything else on the skin yourself? If yes, please list: � � __________________________________________________________________________

MEDICATIONS: (Oral or Topical) a) Are you currently taking ANY medications by MOUTH (including prescriptions, hormones, � � birth control pills, over-the-counter supplements, vitamins and herbals) or suppositories, eye drops, ear drops; or putting anything on your skin? b) If yes, please list: ________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

ALLERGIES: (Oral or Topical medications) Please specify (e.g. rash, hives, itching, etc.) � � Medication:_______________________________ Reaction: ____________________________ Medication:_______________________________ Reaction:____________________________ Medication:_______________________________ Reaction:____________________________

SOCIAL HISTORY: YES NO UNKNOWN What is your Occupation? Have you ever smoked? � � � _________________________________ Do you smoke every day? � � � Do you smoke sometimes? � � � Hobbies? Do you still smoke? � � � _________________________________ Do you drink alcohol regularly? � � ____________________________________ Have you had or been exposed to � � HIV (AIDS)?

YOUR PERSONAL FAMILY HISTORY: Indicate relationship PAST OR PRESENT SKIN CONDITIONS: YES NO (If grandmother or grandfather, INDICATE which one, Skin cancer Type_____________________ � � and ALSO add (m) for maternal or (p) for paternal) Psoriasis � � YES NO Eczema � � Skin cancer � � _____________________________ Other skin condition Please list: � � Psoriasis � � _____________________________ ____________________________________ Eczema � � _____________________________ Asthma � � Asthma � � _____________________________ Hay Fever � � Hay Fever � � _____________________________ Problems healing � � Any other family skin condition? Please list: Thick or elevated scars after surgery � � ________________________________________________ Bleed easily � � ________________________________________________

(PLEASE COMPLETE BOTH SIDES)

Page 2: ORANGE DERMATOLOGY ASSOCIATES, P.C. · 2018-06-08 · (Side 2) YOUR PERSONAL PAST OR PRESENT MEDICAL HISTORY YES NO YES NO High Blood Pressure ’ ’ Colitis/Inflammatory Bowel Disease

(Side 2)

YOUR PERSONAL PAST OR PRESENT MEDICAL HISTORY

YES NO YES NO High Blood Pressure � � Colitis/Inflammatory Bowel Disease � � Heart Attack � � Heartburn/Acid reflux/Ulcers (circle) � � Irregular Heartbeat � � Hepatitis, If yes, what type?_______ � � Phlebitis (Vein inflammation) � � Arthritis/Joint/Muscle Disease (circle) � � Blood clots � � Osteopenia/Osteoporosis (circle) � � Pacemaker � � Artificial joints � � Angina � � Convulsions/Epilepsy/Seizures (circle) � � Heart Surgery � � Multiple Sclerosis or other Neurologic � � Diabetes � � disorders (circle) ___________________ Strokes � � Immune Problems________________ � � Depression � � _____________________________ Thyroid Disease � � Cancer, Type? _________________ � � Kidney Disease/Dialysis (circle) � � Other diseases or conditions not listed above: ___________ ___________________________________ ________________________________________________ List surgical procedures you have had in the last 6 months:_______________________________________________ Name/Address/Telephone No. of your Primary Care Physician : _________________________________________ ______________________________________________________________________________________________ Were you referred by (circle) physician, friend, relative, other? YES NO Name:___________________________________________ � � FEMALES ONLY YES NO YES NO Are you pregnant? � � Are you breastfeeding? � � Did you hear about us on the internet � Yes � No If yes, which website � Google � Instagram � Facebook � Other Please list____________________________ Email Address___________________________________________________ Are you interested in getting emails from us � Yes � No

COSMETIC PROCEDURES: Are you interested in getting or receiving more information and/or promotions? � Yes � No

� LASER hair removal � “FILLER” (Juvederm, Restylane, Radiesse, etc.) injections � LASER removal of facial redness and spider veins � BOTOX Cosmetic � LASER removal of brown or dark spots � COOL SCULPTING for localized fat removal Completed by: � Patient _____________________________________ Date ___/___/___ � Medical Assistant _______ Signed by Patient/Parent/Guardian _____________________________________ Date ___/___/___ Reviewed by

(HAVE YOU COMPLETED BOTH SIDES?)