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Patient Information

*Last Name *First Name Middle Initial

*Email Address *Home Phone

Dermatology	History
Chief Complaint
History of Present Illness
Medications
Allergies

MEDICAL HISTORY (check box if you have or have had any of the following symptoms or diseases)

	Hearing Problems		Glaucoma		Cataracts		Nose Bleeds		Sinus Trouble
	Hoarseness		Hay Fever		Asthma		Hypertension		Coronary Heart Disease
	Heart Murmur		Palpitations		Irreg. Pulse		Varicose Veins		Phlebitis
	Difficulty Swallowing		Heartburn		Peptic Ulcer Disease		Colitis		Jaundice
	Hepatitis		Kidney Stones		Prostate Problems		Venerial Disease		Herpes
	Chlamydia		Gonorrhea		Recent Weight Loss		Anemia		Bruise Easily
	Cancer		Diabetes		Thyroid Disease		Seizures		Stroke
	Migraine Headaches		Arthritis		Gout		Mental Illness		Depression
	Allergies (Non Drug)		Eczema		Psoriasis		Rash		Abnormal Skin
	Hives		Frequent Sun Exposure		Migraine Headaches		Excessive Scarring		Skin Cancer
	Recent or Progressive Hair Loss		Pregnant

Alcohol - oz/wk	Smoking dig/day	Smoking Years	Coffee/Tea - Cups/Day

Family History