Garrott Dermatology

Patient Info:
Patient Name:
Date of Birth:			Today's Date:
Reason for today's visit:
Are you allergic to any medications?		Yes No (if yes, list reasons below)
Reason 1. Reason 2.
Have you ever had dental anesthesia (Novacaine)?		Yes No .......Any bad reaction? Yes No
List all medications you are currently taking (including prescriptions, over-the-counter meds, vitamins, and herbals):
	1.	2.	3.
	4.	5.	6.


Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO)
Lungs:	Yes	No	Other Systemic:	Yes	No
Bronchitis			Diabetes
Emphesema			Excessive thirst/hunger
Asthma			Amputation
Chronic Cough			Thyroid
Morning Cough			Kidney
Shortness of Breath			Dialysis
Wheezing			Bladder
			Frequency/burning
Cardiovascular:	Yes	No	Gastrointestinal:	Yes	No
High Blood Pressure			Stomach absorptive disorder
Chest Pain			Nausea, vomiting, diarrhea when taking antibiotics
Heart Attack			Yes infection when taking antiobiotics
Heart Murmur			Arthritis/Joint Deformity
Irregular Heartbeat			Arthalgia
Phlebities			Limited Motion
Inflammation of vein			Artifical Joint
Blood clots			Convulsions, Epilepsy or Seizures
Pacemaker			Fainting

List any other diseases or conditions:
List surgical procedures you have had in last 6 months:

Skin:	Yes	No
Have you ever had skin cancer?
Has anyone in your family had skin cancer?
Do you have a history of any specific skin diseases?			If yes, please explain.
Do you have problems with healing?
Do you develop keloids (scars) after surgery?
Do you bleed easily?
Do you develop skin rashes in reaction to:
Medications Food Environment Bandages Topical Neosporin
Other ( Explain)

Social History:	Yes	No	If yes:
Do you drink alcohol?			Drinks per day:
Do you use IV drugs?			What?
			How often?
Do you smoke?			How much?
Have you had or have you been exposed to HIV (AIDS)?

Please answer the following questions:
(Women) Are you pregnant?			Due Date:
What is your occupation?
Hobbies?

Completed by: Patient Medical Assistant	Initials as proof of signature:
	Date:
	Reviewed by:
	Date: