Medical History Form Step 1 of 2 50% Date MM slash DD slash YYYY DoctorPatient Name* First Last Date of Birth* MM slash DD slash YYYY Past Medical HistoryPlease check the following boxes if you currently have or in past have had any of the following medical conditions: Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant COPD Coronary Artery Disease Depression Diabetes Elevated Cholesterol Enlarged Prostate GERD Hearing Loss Hepatitis Hypertension Hyperthryoidism Hypothryroidism Kidney Disease Radiation Treatment Seizures Stroke Have you been diagnosed with any type of cancer? Yes No If yes, please list:Past Surgical HistoryWhat operations have you had?Skin Disease HistoryPlease check the following boxes if you have had any of the following skin or skin-related conditions: Acne Actinic Keratosis Asthma Basal Cell Skin Cancer Blistering Sunburns Dry skin Eczema Itchy/Flaking Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Do you wear sunscreen? Yes No If yes, what SPF?Do you or have you ever tanned in a tanning salon? Yes No Family HistoryHas anyone in your family had melanoma? Yes No If yes, which relative?Please list your current medications: Are you allergic to any medications? Yes No If yes, please list: Have you ever smoked? Yes No Do you currently smoke? Yes No Do you drink alcohol? Yes No If yes, how much? Less than 1 drink per day 1 to 2 drinks per day 3 or more drinks per day HeightCurrent WeightReview of SystemsPlease check the boxes if you are currently experiencing any of the following: New skin lesion Joint aches Rash GI upset with antibiotics Problems with bleeding Problems with healing Problems with scarring (keloids) Immunosuppression Anxiety/Depression Headaches Thyroid Problems Unexplained weight loss Changing mole Pacemaker/Defibrillator Artificial joints within past two years Artificial heart valve Premedication prior to procedures Allergy to adhesive Allergy to topical antibiotic ointments Blood thinners Allergy to lidocaine Rapid heartbeat with epinephrine Yeast infections with antibiotics Latex allergy CAPTCHA