DERMATOLOGY GROUP OF ARKANSAS, P.A.
 
PATIENT MEDICAL HISTORY
 
Patient Name: Date: / /

Reason for today’s visit:

Are you allergic to any medications? Yes No If yes, please list:

List all medications you currently take, including prescription, over-the-counter medications, vitamins, supplements 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)  
LUNGS YES NO OTHER SYSTEMIC   YES NO
Bronchitis Diabetes  
Emphysema Excessive thirst/hunger  
Asthma Thyroid  
Chronic Cough Kidney  
Morning Cough Bladder  
Shortness of Breath Frequency/Burning  
Wheezing Gastrointestinal  
CARDIOVASCULAR     Stomach absorptive disorder  
High Blood Pressure Nausea vomiting, diarrhea when taking    
Chest Pain antibiotics  
Heart Attack Yeast infection when taking antibiotics
Heart Murmur Arthritis / Joint Deformity  
Irregular Heartbeat Arthralgia  
Phlebitis Limited motion  
Inflammation of veins Convulsions, Epilepsy or Seizures  
Blood clots Fainting  
Pacemaker        
List any other diseases or conditions:
List surgical procedures you have had in the last 6 months:
SKIN:        
Have you ever had skin cancer?     YES NO
Has anyone in your family ever had skin cancer? YES NO
Do you have a history of any specific skin diseases? YES NO
Do you have problems with healing?   YES NO
Do you develop keloids (scars) after surgery? YES NO
Do you bleed easily?       YES NO
Do you develop skin rashes in reaction to: Medications Foods Environment
SOCIAL HISTORY:        
Do you drink alcohol? YES NO If YES, drinks per day.
Do you use IV drugs? YES NO If YES, what? . How often?
Do you smoke? YES NO If YES, how much?
Have you had or have you been exposed to HIV (AIDS)? YES NO
Please answer the following questions:      
(Women) Are you pregnant? YES NO Due date: / /
What is your occupation?
Hobbies?
Do you require pre-medication prior to surgery due to artificial joints/heart valves? YES NO
If yes, please list drug:
Completed Patient / /
by:
Medical Signed by Patient Date
 
     
  Assistant    
    Initials / /
DGA0005 Reviewed by Date