Medical History Questionnaire | North Metro Dermatology

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Full Name *

Date of Birth *

Why are you seeing a physician today? *

PERSONAL MEDICAL HISTORY

If you have had any other disease or condition, please list below:

PERSONAL DERMATOLOGIC HISTORY

If you have had any other dermatologic condition not listed above, please list below:

SOCIAL HISTORY

Ever use Alcohol? *

Ever use Tobacco? *

Yes, I am a current user
No
Previous Use

Drug use (marijuana included) *

Yes
No
Previous Drug Use

List current medications that you are taking or receiving (including prescriptions, infusions, over-the-counter meds, herbal supplements and the dosages). *

Are you allergic to any medications? *

If you are allergic to certain medications, please list them below:

Have you ever had a reaction to lidocaine, novocaine, bandages, latex, or topical antibiotics (i.e. Neosporin, Bacitracin)? *

If yes, please list:

Have you ever had a pacemaker? *

Do you have a defibrillator? *

Are you pregnant or breastfeeding? *

Are you planning a pregnancy? *

Referring Physician ( Please provide Physician's name and clinic/location ): *

If not applicable, please type "N/A"

Primary Care Physician ( Please provide Physician's name and clinic/location ): *

If not applicable, please type "N/A"

Preferred Pharmacy ( Please list name and address ): *

If not applicable, please type "N/A"

Are you a previous patient of ( Please choose one of the below )? *

Dr. Rahil
Dr. Long
I'm a new patient

Have you seen either physician ( Dr. Rahil or Dr. Long ) within the last three (3) years? *

By typing my full name below, I agree that all of the above information is true to the best of my knowledge. *