Dermatology Medical History

specific skin diseases?_ YES_ NO If yes, what? ________________________________ Do you bleed easily, or have a bleeding disorder?_ YES_ NO List any other diseases or conditions: ____________________________________________________________________________ ____________________________________________________________________________________________________________ List surgical procedures you have had in the last 6 months: _________________________________________________________ Women 3Menstrual History Last Menstrual Period : _________________ Are you pregnant?<br><br> _ YES _ NO Are you trying to become pregnant? _ YES _ NO If pregnant, OB/GYN physician: _______________________ weeks gestation?_________ estimated due date?__________________ Social History: Do you drink alcohol? _ YES _ NO If YES, how many drinks per day?<br><br> _______________________________________ Do you smoke? _ YES _ NO If YES, how much: ___________________________________________________ Have you had or have you been exposed to HIV / AIDS or Hepatitis C? _ YES _ NO What is your occupation?<br><br> ___________________________________________________ Who is your Primary Care Physician (pedi, family med, internal med)?___________________________________________________ _____________________________________________ _______________ Signature of Patient / Legal Guardian Date _________

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