Patient History FormPatient History FormSelf Entered History Step 1 of 333%Your Personal InformationYour Name First Last Your Email Address Enter Email Confirm Email Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Your PhoneYour Mobile PhoneHow will you be paying for treamtent?Traditional Medicare, Railroad Medicare, or TricareMedicare Advantage PlanCommercial InsuranceSelf-Pay (we do not take Obamacare plans)Upload a picture of the FRONT AND BACK of your insurance cardUpload in .jpg. gif, pdf format Drop files here or Select filesAccepted file types: jpggif, pdf, Max. file size: 25 MB.Let's get some information about your medical historyMedications and SupplementsList all prescription medications, supplements, and Vitamins that you take. Include dose and how often you take these products.AllergiesAre you allergic to any of the following Adhesive, Band-Aids, Mastisol Neosporin Polysporin LatexAllergies (medicines and topical not listed above)Please list all allergies and the type of reaction that you have gotten.Do you use any of the following Never used tobacco Former tobacco user tobacco – smoke less than 1 pack per day tobacco – smoke MORE than 1 pack per day Tobacco – chew DAILY Tobacco – chew SOCIALLY, not daily Cocaine Other stimulants Narcotics Downers Other Alcohol – socially, not daily Alcohol – daily I do not consume alcoholPlease check off any health issues that you currently have. Allergies – Hay fever, seasonal allergies Arthritis, Osteoarthritis type Arthritis, Psoriasis type Arthritis, Rheumatoid type Autoimmune disease – Lupus or other Bleeding or clotting problems Cancer – other than skin Eyes – Glaucoma Eyes – Other problem Gout Heart – Coronary Artery Disease (CAD) Heart – Arrhythmia – Irregular heart beat Heart – Other problems Keloids Kidney disease Liver – Hepatitis Liver – not hepatitis) Lung – Asthma Lung – Emphysema Lung – Other Lymphedema – swelling of the legs and/or arms Muscular problems Neurological problems (except Parkinson’s) Parkinson’s Disease Prostate Enlargement Psychiatric – Anxiety Psychiatric – Depression Psychiatric illness – Other STD Thyroid disease Urinary or bladder problems Vasculitis Other (not listed above) NONE OF THE ABOVEExplain Further if neededAny other medical (non-skin) problems not listed above or those that need further explainationDo you have any of the following Chills Fever Anxiety Wheezing or shortness of breath chest pain Nausea or vomiting diarrhea or constipation Fatigue excessive thirst or hunger excessive urination numbness or tingling depressed mood seizures blood in urine painful urination difficulty urinating leg swelling leg cramps joint pain fatigueSkin HistorySkin CancersCheck all that you have had, if any. Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma Merkel Cell Other NONEExplain Further if neededAdditional information regarding skin cancer history–diagnosis, sites, when diagnosed, etc.Other Skin Conditions Acne Atopic Dermattiis Contact Dermatitis Dry Skin (Xerosis) Dyshidrosis Eczema Folliculitis Genital Warts Hand Dermatitis Lymphedema Psoriasis Rosacea Seborrheic Dermatitis or Dandruff Vasculitis Warts OtherAdditional informationAny other skin conditions, or information regarding the above including treatments used, etc.
