Comprehensive Dermatology Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________________
• Address: _________________ Phone: _________________
• Email: _________________ Insurance: _________________

Primary Concern

• Main reason for visit: _________________
• Duration of symptoms: _________________
• Location on body: _________________
• Previous treatments tried: _________________

Skin History

Current Symptoms (check all that apply):

□ Rash □ Itching □ Burning □ Bleeding □ Changes in moles □ Skin lesions □ Hair loss □ Nail changes

Past Skin Conditions:

□ Acne □ Eczema □ Psoriasis □ Skin cancer □ Melanoma □ Other: _________________

Medical History

General Health Conditions:

□ Diabetes □ High blood pressure □ Heart disease □ Thyroid disorder □ Autoimmune conditions

Medications

• Current medications: _________________
• Allergies to medications: _________________
• Topical products used: _________________

Family History

□ Melanoma □ Skin cancer □ Psoriasis □ Eczema

Social History

• Sun exposure: □ Minimal □ Moderate □ Frequent
• Sunscreen use: □ Daily □ Occasional □ Never
• Smoking status: □ Current □ Former □ Never
• Occupation: _________________

Female Patients

• Pregnant: □ Yes □ No
• Breastfeeding: □ Yes □ No

Consent

I confirm that the information provided is accurate to the best of my knowledge.

Signature: _________________ Date: _________________