Dermatology

                                                                                                                       Robert M Rosen, D. O.

Dermatology Medical History

Patient:  

Date of Appointment: 

Reason for visit: 

Are you allergic to any medications?        

 YES  NO

 If yes, list:   
Have you ever had dental anesthesia (Novocaine)?  YES  NO   

Any bad reaction?   

 YES    NO

List all medications you are currently taking (including prescriptions, over-the-counter meds., vitamins, and herbals):

1.  3.   5. 

2.  4.   6. 

Do you have now, or have you ever had diseases or conditions of:  (Please check YES or NO) 
Bronchitis Heart Attack
Emphysema Irregular Heartbeat
Asthma High Blood Pressure
Chronic Cough Heart Murmur

Phlebitis (Blood clots)

 Pacemaker
Inflammation of vein Bladder problems

Morning Cough

 Frequency/burning
Shortness of Breath Amputation
Wheezing Thyroid disorder
Diabetes Fainting (syncope)
Excessive thirst/hunger Convulsions, Seizures
Yeast infections Kidney Disease
Nausea, vomiting Dialysis
frequent diarrhea Arthritis
other digestive disorder Artificial joint
keloids (scars) Cancer (other than skin)
easily bleeding
List surgical procedures you have had in the last 6 months:
List any other diseases or conditions:
Skin: YES   NO
Have you ever had skin cancer?   
Has anyone in your family had skin cancer? 
Do you have a history of any specific skin diseases?
If yes
Do you have problems with healing   

Social History:

Do you drink alcohol?    

 YES  NO 
If YES (choose number from list)  drinks per day

Have you used IV drugs?   

 YES NO 
  If YES, what? When last?

Do you smoke?  

 YES NO
If YES, how much:

Have you been exposed to HIV (AIDS)?   

 YES  NO

Other habits?

Please answer the following questions:

Do you develop skin rashes in reaction to:  Medications,   Food,   Environment,   Bandages,   Topical Neosporin, Other allergies

 (Women) Are you pregnant?   YES , NO  Due Date:

What is your occupation? 

Hobbies?

Completed by:   Patient Date

Click "Select". You will be able to review your answers prior to Emailing them on the next page.