Skin Surgery Center: Health History HEALTH HISTORY Last Name:     First Name:  Age of Patient: Gender: M F    Date: Name of Dermatologist:  Phone Number:  Name of Primary Care Physician:  Phone Number:  Reason for today's visit:  Skin areas involved:  How long has the problem been present?  Any previous treatment to this area?  Yes   No If yes, when?  Type of treatment done:  Was a biopsy done?  Yes   No   CHECK ALL THAT APPLY TO TODAY'S VISIT Quality A change in: Size Elevation Other Color Hardness None Modifying Factors A history of: X-ray treatments UV light treatments Immunosuppression Arsenic exp./treatments Chronic scar None Associated Symptoms Bleeding Pain Infection Other Tingling Ulceration Itching   Severity No symptoms   Occasional symptoms   Constant symptoms   SYSTEM REVIEW - check all that apply List all medications you are currently taking: Do you have any allergies to medications? Yes   No If yes, list:  Major illnesses or Hospitalizations?  Yes   No If yes, list: SKIN Abnormal scarring   Poor healing   Other skin disorders NEUOROLOGICAL Normal   Stroke   Seizures   Other CONSITUTIONAL SYMPTOMS None   Weight loss   Fever   Other EYES/EARS/NOSE/THROAT Normal   Glaucoma   Hearing aid   Plastic Surgery HEMATOLOGICAL/LYMPHATIC Normal   Anemia   Bledding problems   Enlarged lymph nodes RESPIRATORY Normal   Asthma   Emphysema   Other lung problem GASTRONINTESTINAL Normal   Stomach ulcer   Colitis   Other GI problem MUSCULOSKELETAL Normal   Arthritis   Artificial joint   Metal rods or pins Other CARDIOVASCULAR Normal   Angina   Artificial heart valve   Pacemaker Hypertension   Heart Attack PSYCHIATRIC Normal   Depression   Anxiety Attacks   Other ENDOCRINE Normal   Diabetes   Thyriod   Other INFECTIONS None   Hepatitis   HIV/AIDS   Tuberculosis (T.B.)   Other Previous sunburns: Mild   Moderate Blistering Do you wear? Dentures   Glasses Contact lenses Smoker  Yes   No Former    If yes, packs per day:  Do you drink alcohol?  Yes   No Problems with alcohol or drugs/addictions?  Yes   No If yes, describe:    PAST HISTORY Previous Skin Cancer  Yes   No Location of skin cancer:  Type of Skin Cancer: Melanoma   Basal Cell   Squamous Cell   FAMILY HISTORY Skin Cancer None   Melanoma   Basal Cell   Squamous Cell   SOCIAL HISTORY Retired?  Yes   No Occupation or former occupation: Where did you grow up? City:     State:     Country:  Marital Status:  Single   Married Divorced
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