Microsoft word - derm & vein medical history - update.doc
Girish S. Munavalli, MD, MHS J. Blake Goslen, MD
PATIENT MEDICAL HISTORY
Last Name: _____________________ First Name: ____________________ M.I. _______ D.O.B: ___________ Age: ____
Referring Physician or Source (ie. Magazine, etc):________________________________\___________________________________
Surgical History (list all surgeries & dates): ________________________________________________________________________
Have you been hospitalized for any other reason: ____________________________________________________________________
List any other disease or condition we should know about: ____________________________________________________________
Drug Allergies (please list and briefly describe reaction): ______________________________________________________________
Do you have an allergy to Sulfa/sulfa drugs? □ Yes □ No
If yes, briefly describe reaction: _______________________________
Do you take any blood thinners, such as Coumadin, Plavix, or products containing aspirin (ex: Advil) on a regular basis? □ Yes □ No
Current Medications (including OTC medications & herbal supplements): ________________________________________________
Are you on hormone therapy, estrogen, premarin, provera, birth control, etc. ? _____________________________________________
Are you pregnant ? □ Yes □ No □ NA
Do you have artificial joints? □ Yes □ No
Are you presently breast feeding? □ Yes □ No Previous x-ray or radiation exposure/therapy? □ Yes □ No
How many times have you been pregnant? _______
Have you ever had a reaction to anesthetia? □ Yes □ No
Do you routinely take antibiotics for dental procedures? □ Yes □ No
Have you ever been tested for HIV/AIDS? □ Yes □ No
If yes, when? __________________ Result: □ Positive □ Negative
HISTORY OF DISEASES: Please check YES or NO to the following questions if you have now or have ever had the below diseases and/or conditions:
YES/NO VASCULAR SYSTEMIC LUNGS YES/NO VEIN SYMPTOMS PERSONAL AND FAMILY HISTORY OF SKIN CONDITIONS: When you are exposed to sun, do you:
□ Tan Always □ Tan/Burn □ Burn Always
Has anyone in your family had skin cancer? □ Yes □ No Do you have a history of any skin diseases?
If yes, please list: ______________________________________________________________
If you answered YES to any of the VEIN SYMPTOMS or are here for a VEIN CONSULTATION (spider vein or varicose vein) please complete the remaining questions on the back of this page and sign the consent for treatment. If you DID NOT answer YES to any of the VEIN SYMPTOMS you may skip the remaining questions on the back of this page while still signing the consent for treatment. FAMILY HISTORY OF VARICOSE VEINS/SPIDER VEINS/LEG ULCERS/BLOOD CLOTS OR SWOLLEN LEGS. (please circle which relatives have had any of these) Mother Father Sister Brother
Grandmother Grandfather Other _____________
PREVIOUS VEIN TREATMENT HISTORY: □ Vein Stripping
If so, when and where? ______________________________________________________________________
PERSONAL HISTORY OF VARICOSE VEINS OR SPIDER VEINS: YES/NO YES/NO □ □ Varicose Veins – how many years present? ____ □ □ Symptoms are worse with prolonged standing/sitting? □ □
□ □ Symptoms are worse during menstrual cycle?
□ □ Do you elevate your legs to relieve discomfort?
If so, how many months/years? __________________________________________
□ □ Is your discomfort/leg pain getting worse?
□ □ Does your discomfort interfere with your daily living?
In what way? 1. ____________________________________
Work related interference: _______________________________________________________________________
□ □ Do you take medication for leg pain (aspirin, advil, mortin, ibuprofen, other)?
If so, how long? _______________________________________________________
□ □ Have you ever worn support hose prescribed by a doctor.
If so, how long? ___________________ What doctor? ____________________ Location: ___________________
□ □ Did the hose provide relief to your symptoms? □ □ Have you ever had your veins evaluated before?
If so, when and where? _________________________________________________
Did a physician refer you to our office for this vein consultation? If yes, please provide the following:
Doctor’s name: _______________________ Address: ____________________________ Phone: ___________________
Physician Signature: _________________________________ / MA Initials: ____________ Date: _____________
CONSENT FOR TREATMENT
I hereby give my consent for medical examination and treatment. I understand that no therapy is guaranteed. It is the policy of Dermatology, Laser & Vein Specialists of the Carolinas that no substantial procedures are performed upon me until I have an opportunity to discuss it with Dr. Goslen, Dr. Munavalli, or other healthcare professionals to my satisfaction. I also consent to the taking of photographs for my medical record. I have provided this clinic a list of all medications (both prescribed and over the counter) that I am currently using. I have reviewed the statement and agree to abide by the guidelines for my treatment.
Patient Signature: _______________________________________
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