EmailMeForm
MEDICAL HISTORY FORM
SOUTHEASTERN DERMATOLOGY GROUP, P.A.
Dermatology Specialists of Alabama, Florida, Georgia, and Mississippi
877-231-DERM (3376)
Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Have you ever had Skin Cancer?
Yes
No
If yes, was it:
Basal Cell
Squamous Cell
Melanoma
Place a check box in all that apply
Where was it located? How and when was it treated?
Do you have family history of Basal Cell, Squamous Cell, or Melanoma?
Yes
No
Do you have dry skin, eczema, or psoriasis?
Yes
No
Do you have a family history of dry skin, eczema, or psoriasis?
Yes
No
Do you have any chronic medical condition or skin conditions? (Please list all)
Please list all current mediciations (including creams):
Are you currently on blood thinners?
Yes
No
Please list all drug of food allergies (including latex, lidocaine, and adhesives)
Do you have a pacemaker or defibrillator?
Yes
No
Do you have any artificial joints or valves?
Yes
No
Do you take antibiotics prior to dental procedures?
Yes
No
Please list any prior surgeries you have had (Surgery/Month/Year):
Do you or have you ever smoked?
Current
Former
Never
How many cigarettes a day do you smoke?
Do you have a history of drug use?
Yes
No
Did you have a drink containing alcohol in the past year?
Yes
No
If 'Yes': How often did you have six or more drinks on ONE occasion in the past year?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
If 'Yes': How many drinks did you have on a typical day when you were drinking in the past year?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
If 'Yes": How often did you have a drink containing alcohol in the past year?
Never
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
Have you ever receiving the pneumonia Vaccine? If yes, date (Month/Year)
Have you ever had the flu shot within the last year? If yes, date (Month/Year)
Do you exercise?
Yes
No
Do you have any body piercings?
Yes
No
Do you have any tattoos?
Yes
No
Have you ever used a tanning bed?
Yes
No
Are you interested in cosmetic procedures?
Yes
No
If you are interested in cosmetic procedures, please provide your email address
Have you ever had Botox or other cosmetic procedures? If yes, what did you have?
Do you currently have a skin care regimen? If yes, what are you using?
Are you receiving improvement from your current regimen?
Yes
No
Do you wear sunscreen?
Daily
When exposed
Never
Are you interested in a cosmetic consultation with our Aqua Medical Spa?
Yes
No
