Patient’s Name: ___________________________________________________

Date of Birth / /
Today’s Date / /________

Have you been diagnosed and/or treated for any of these conditions?

(Please Check All That Apply)
_______Irregular Heart Beat (arrhythmia) _______Kidney Disease requiring Dialysis ______Inflammatory Bowel Disease (Crohn’s Disease or Ulcerative Colitis) Cancer, please specify:________________________________ Skin Cancer BCC___________________________________SCC_____________________________________________ Melanoma site____________________when diagnosed_____________________ treatment______________________ Have you received a Blood Transfusion? Y or N Have you received X-ray Treatments for Acne? Y or N Have you received Light Treatment for any Kind of Skin Condition? Y or N Have you received Radiation Treatment for a Cancer? Y or N
Do You?
(Please check All that apply)
Require Antibiotics Prior to Dental Procedures? Develop Rashes / Reactions to Bandages / Tapes / Antibiotic Ointments?
Do you have any other medical conditions not previously mentioned? If yes, please list:
Please list all major SURGERIES:_______________________________________________________

Females Only: (
if the patient has not undergone changes of puberty, circle n/a) N/A
Do you develop frequent yeast infections when taking antibiotics? Y or N Have you had your uterus removed (hysterectomy)? Y or N Have you had your ovaries removed? Y or N Have you had one or more miscarriages? Y or N Y or N If so, when was last menstrual period? ___________
Medication History:

Do you have any Medication Al ergies? Y or N If yes, please list: __________________________________________________________ Other Al ergies? Seasonal/foods/environmental? _________________________________ _______________________________________
Please list all medications you are currently taking (prescriptions, over-the-counter meds, vitamins & herbal supplements):
______________________ ____________________ Patient’s Name: ______________________________________________
P. 2 Med Hx
Do you ever take aspirin, ibuprofen (Motrin, Advil) naproxen sodium (Al eve, Naprosyn), vitamin E supplements, garlic, ginger, gingko or ginseng supplements? If yes, please list the items you do take and describe how often. ____________________________________________________________________________________________________ Have you ever had a reaction to local or general anesthesia? Y / N Have you ever had a reaction to Epinephrine?
Family History:
Do you have any family members (father, mother siblings or child) with the fol owing conditions?
(Please check ALL that apply.)
____ Skin Condition (Please List)________________________ Are there any other diseases / conditions which run in your family? If yes, please list:_______________________________ Social History:
Married / Separated / Divorced / Partnered Do you use tobacco products of any kind? Y or N If yes, list type_____________________ Amount per day___________________ If yes, how much? (# of drinks per day, week, or month)________________________ Do you or have you ever used recreational drugs? Y or N If yes, what? _______________________ Route taken? (Oral, IV, nasal, smoke) Have you ever been exposed to HIV? Y or N What is your occupation?_______________________________________________________ Hobbies?_______________________________________________________________ Review of Systems: Are you experiencing any of the fol owing symptoms currently or in the last 6 months?
(Please check ALL that apply)
Women Only:
Digitally signed by Skin Solutions Dermatology DN: cn=Skin Solutions Dermatology, o=Skin Solutions, c=US When exposed to the sun in the spring (first significant sun exposure of the warm season), do you (Please check ONE)
_____ Sometimes Burns, Always Tans (I I) Patient Signature __________________________________ Date / / Reviewed & Updated / / Initial . Legal Representative__________________________________ Date / / Reviewed & Updated / / Initial . Physician’s Signature Date / / Update Reviewed / / Initial . 7 West 24th Street, 1st Floor, New York, NY 10010  T 646.559.0843 F 646.559.0845



The New Yorker SUPERASPIRIN A new kind of drug could make Motrin and Aleve obsolete. It treats arthritis like nothing else. Can it treat cancer and Alzheimer's, too? BY JEROME GROOPMAN June 15, 1998 In the autumn of 1979, I began to train for the Boston Marathon. Each day I ran from my laboratory, at the Harvard Medical School, along the Charles River and back—some fiftee

Confidential health history

CONFIDENTIAL HEALTH HISTORY Patient Name: ______________________________________________________________ Date of Birth: ______________________ I. CIRCLE APPROPRIATE ANSWER (Leave blank if you do not understand the question) 1. Yes No If NO, explain__________________________________________________________________________ Has there been a change in your health within the last year? I

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