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Medical History Questionnaire
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
Please check all of the below medical conditions that apply (If not applicable, please check "None of the Above"):
*
Anxiety
Arthritis
Asthma
Atrial Fibrillation (Irregular Heartbeat)
Cancer
Coronary Artery Disease (Heart Disease)
Depression
Diabetes
GERD (reflux / heartburn)
Hepatitis
High Blood Pressure
High Cholesterol
HIV / AIDs
Inflammatory Bowel Disease (IBD)
Kidney Disease
Liver Disease
Lupus
Seizures
Stroke
Thyroid Disease
None of the Above
If you have had any other disease or condition, please list below:
PERSONAL DERMATOLOGIC HISTORY
Please check all of the below dermatologic conditions that apply (If not applicable, please check "None of the Above"):
*
Actinic Keratosis
Basal Cell Carcinoma
Dysplasic / Atypical Moles
Eczema
Keloids
Melanoma
Psoriasis
Squamous Cell Carcinoma
None of the Above
If you have had any other dermatologic condition not listed above, please list below:
SOCIAL HISTORY
Ever use Alcohol?
*
Yes
No
Ever use Tobacco?
*
Yes, I am a current user
No
Previous Use
How often do you use alcohol?
*
Social
Moderate
Heavy
None
How often do you use tobacco?
*
Social
Moderate
Heavy
None
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?
*
Yes
No
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)?
*
Yes
No
If yes, please list:
Have you ever had a pacemaker?
*
Yes
No
Do you have a defibrillator?
*
Yes
No
Are you pregnant or breastfeeding?
*
Yes
No
Are you planning a pregnancy?
*
Yes
No
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?
*
Yes
No
By typing my full name below, I agree that all of the above information is true to the best of my knowledge.
*
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