AFFZ11 Patient History Form

PATIENT HISTORY FORM

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

Primary Care Physician *

First Name

Last Name

Referring Provider

First Name

Last Name

Your Occupation

Preferred Pharmacy *

Pharmacy Address *

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Pharmacy Phone Number

Please enter a valid phone number.

Mail Order Pharmacy

Do you take any prescription medications, including vitamins or supplements?

Yes

No

If yes, please list below

Do you have allergies to medication?

Yes

No

If yes, please list and give type of reaction

	Allergic to	Reaction
1.
2.
3.
4.
5.

Past Medical History

	Yes	No
Abnormal Moles
Eczema
Asthma
Seasonal Allergies / Hayfever
Hypo / Hyper Thyroidism
Diabetes
Arthritis
Autoimmune Disorder
HIV
Cancer-List Type below
Liver Disease/Hepatitis
High Blood Pressure
Pacemaker
Mitral Valve Prolapse
Heart Valve Replacement
Joint Replacement
Blood Disorder
None of the Above

Do you have other medical conditions not listed above?

If you checked Cancer above, please list type here

Past Family & Personal Medical History

	Personal	Family	Details
Basal Cell Carcinoma
Squamous Cell Carcinoma
Malignant Melanoma
Psoriasis

Past Surgical History and Hospitalizations: (List all)

Please check YES or NO

	Yes	No
Do you wear sunscreen?
Do you use indoor tanning?
Have you ever had a severe reaction to local anesthesia?
Are you allergic to adhesive?
Are you allergic to topical antibiotic ointments?
Are you taking blood thinners?
Have you been told to take antibiotics prior to dental or surgical procedures?
Have you had an adverse reaction to epinephrine?
Are you planning a pregnancy?

Number of alcoholic drinks per week? *

None

Less than 1 per day

1-2 per day

3 or more per day

Smoking Status *

Current, everyday

Current, some days

Former

Never

Skin Type

If you were first exposed to the summer sun without sunscreen, would you *

1. Always burn, never tan

2. Always burn, sometimes tan

3. Sometimes burn, always tan gradually

4. Burn minimally, always tan well

5. Rarely burn, tan profusely

6. Never burn, deeply pigmented