MEDICAL mSTORY

GEORGETOWN DERMATOLOGY

TODAY'S DATE

SEX MIDDLE

NAME __ ~ ____________ ~ __________ =-~~ __ __ LAST FIRST

DOB

Reason for today's visit: ________________________________________ _

Are you allergic: to any medications? o Yes O No If yes. list below:

1. __________________ _ 2.

Have you ever had dental anesthesia (Novoc:ain)? o Yes ONo Any bad reactions? o Yes ONo

Do you have an artificial heart valve, joint, or other prosthesis that require you to take antibiotics when you have dental procedures? 0 Yes ONo If yes, what antibiotic, ________________ _

List all medications you are currently taking (including prescriptions, over the counter meds, vitamins and herbals) I. 4. ________________________________ _ 2. 5. _________________ _ 3. 6. _________________ _

Do you have now or have you ever had diseases or conditions of: (Please circle Yes or No)

LUNGS: GASTROINTESTINAL:

Bronchitis YES NO Stomach absorptive disorder Asthma YES NO Nausea, vomiting, diarrhea Emphysema YES NO when taking antibiotics Hay fever YES NO Yeast Infection when Shortness of Breath YES NO taking antibiotics Wheezing YES NO

CARDIOVASCULAR: OTHER SYSTEMS:

High Blood Pressure YES NO Diabetes Chest Pain YES NO Excessive thirstlhunger Heart Attack YES NO Thyroid Heart Murmur YES NO Kidney Irregular Heartbeat YES NO Dialysis Phlebitis YES NO Arthritis/Joint Deformity Blood clots YES NO Limited Motion Pacemaker YES NO Arthralgia Inflammation of v;~in YES NO Artificial Joint

Convulsions, Epilepsy, or Seizures Fainting

List any other diseases or conditions:

YES NO

YES NO

YES NO

YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO YES NO

YES NO YES NO

List surgical procedures you have had in the last 6 months: _________________ _

SKIN:

Have you ever had skin cancer? 0 YES 0 NO

o Basal Cell Carcinoma 0 Squamous Cell Carcinoma 0 Malignant Melanoma _ (depth)

Has anyone in your family had skin cancer? 0 YES 0 NO

o Basal Cell Carcinoma [J Squamous Cell Carcinoma o Malignant Melanoma _ (depth)

3301 New Mexico Avenue, NW Suite 210, Washington, DC 20016 Phone 202.363.9600 FAX 202.363.9601

VERSION 5-29-2009

GEORGETOWN DERMATOLOGY

Do you have a history of specific skin diseases?

Did you have any Blistering Sun Burns?

Do you have a problem with healing? Do you develop keloids (scars) after surgery? Do you bleed easily? Do you develop skin rashes in reaction to: Band-Aids Tape or adhesive Food Environment Topical Neosporin Other:

D YES D YES D YES

D YES D YES D YES D YES D YES

D YES D NO If yes, list below:

D YES D NO If yes, list below:

D NO D NO D NO

D NO D NO D NO D NO D NO

WE OFFER A FULL RANGE OF COSMETIC PROCEDURES.

Please indicate whether you are interested in learning more about:

D BOTOX D RESTYLANE D RADIESSE D JUVEDERM D PERLANE

D LASER TREA TMENTS (FACIAL REDNESS, SUN SPOTS, LEG VEINS, HAIR REMOVAL, PHOTOREJUVENA TION)

D CHEMICAL PEELS D CUSTOM ANTI-AGING SKINCARE PRODUCTS D SUNSCREENS

If any of these are of interest to you, please let us know and we can discuss them with you.

SOCIAL mSTORY:

Do you drink alcohol? Do you use IV drugs Do you smoke? Have you had or have you been exposed to HIV (AIDS)

FEMALE PATIENTS ONLY:

Are you taking oral contraceptives? Are you pregnant or trying to become pregnant?

D YES D NO If YES, drinks per day D YES D NO If YES, what? How often? __ _ D YES D NO If YES, how much? ____ _ D YES D NO

D YES D NO D YES D NO If YES, due date? __ 1 __ _

What is your occupation? _________ Hobbies? ________________ _

Completed by:

Signed by patient __________________ TODA Y'S DATE, ________ _ Reviewed by Medical Assistant Initials Date Reviewed by MD _______________________________ _

Initials Date

3301 New Mexico Avenue, NW Suite 210, Washington, DC 20016 Phone 202.363 .9600 FAX 202.363.9601

VERSION 5-29-2009