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. ____________________________________ 2. _____________________________________ 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: _______________________________________

Source: http://www.carolinaskin.com/forms/MedicalHistory.pdf