Joseph J. SchwarE, M.D.Dermatology Medical History
Potient: Dote:
Reoson for todoy's visit:
Are you ollergic to ony medicotions?].
E] NO lf yes, list:I] YES
2.
Hove you ever hod dentol onesthesio {Novocoine)? tr YES tr NO Any bod reoction? tr YES tl NO
List oll medicolions you ore currenilyloking (including prescriptions, over-the-countermeds., vitomins, ond herbols):t.2.
3.4.
Do you hove now, or hqve you ever hod diseoses or conditions of: (Pleose check YES or NO)Lungs:
Bronchitis
Emphysemo
Asthmo
Chronic CoughMorning CoughShortness of Breoth
Wheezing
Cordiovosculor:High Blood Pressure
Chest Poin
HeortAttockHeortMurrnurlrregulor HeortbeotPhlebitis
lnflomotion of veinBlood clots
Pocemoker
YES NOtrEIBtrtrtrUEItrtrE] E]utrY-ES
trtrBDtrtrtrtrtr
NOtrEI
truuuEI
Etr
OlherSystemic:Diobetes
Excessive th i rst/h u n g e rThyroid
Kidney
BlodderFrequency/burning
GostrointestinolStomoch obsorptive d isorderNouseo, vomiting, d io rrheo
when toking ontibioiicsYeost infection when
toking ontibioticsArth ritis/Joint Deform ity
ArthrolgioLimited motionA*ificisl ioint
Convulsions, E pilepsy or Seizures
YEs NOtrtrEItrtrEIatrEtrtrn
trutr[]trEltrtrEIurItrtra
trntrtrtrEI
Skin:When you ore exposed to sun do you:Hove you ever hod skin concer?Hos onyone in yourfomily hod skin concer?Do you hove o history of cny specific skin diseoses?If yes, pleose list:
EJ Ton ond burn tl Burn
trNOtr NO If YES, WhO?uNo
Fointing
E Ton onlytr YES
N YES
B YES
Do you develop skin roshes in reoction to E Medicotions E Food tr Environmenl?
List ony other diseoses or conditions:Lisf surgicol procedures you hove hod in the lost 6 months:
Socinl History:Do you drink olcohol?Do you use lV drugs?Do you smoke?
YES I NO lf YES drinks per doyYES tr NO lf YES, whot?YES n NO lf YES, how much:
Hsve you hod or hove you been exposed to HIV (AIDS) ? tI YES tr NO
Pleose o nswer the following questions :
A. Do you bleed eosily?B. (Women) Are you pregnont? Dy* Dote:C. Whot is your occupotion ?
D. Whot ore your hobbies?
Completed by:Signed by Potient
hiti"lt@2002 lnga Ellzey Practice Group, lnc. May be reproduced for personal use only.
trtrtr
How much?
E] YES E] NOE] YES tr NO
tru
PotientMedicol Assistont Dote
Reviewed by Dote
Joseph J. Schwartz, M.D,
Name Date of Birth I I M/t'
Address Age
City State_ Zip
Phone (H)
Emergency Contact: ]rlame
Phone (W)
Phone
Insurancs Information
Co-Pay S
Insurancs Company
ID# Group #
Subscriber of trnsurance Relationship
Date of Birth I I Phone (H)
Secondary Insurancs
ID# Group #
Suhscriber of Insurance Relationship-
Date of Birth I I Phone (H)
Primary l)octor Phone Fax
Address
How did you hear about our practice?
Assignment and release: I hereby authorize my insurance benefits be paid directly to thephysician and acknowledge that I am financially responsible for any unpaid balances. Ialso authorize the physician to release any information required by the insurancecompany, including medical records. I understand that I am financially responsible for allcharges, whether or not covered by insurance.
Signed Date I I