Name
Email
Date of Birth
Date of Visit
File No.
Do you have any allergies? YesNo
Have you had any surgeries? YesNo
Do you have any medical conditions? Diabetes mellitusHypertensionHeart diseaseAsthmaCOPDCancerThyroid problem
Have you experienced any of the following symptoms in the past 6 months? Chest painShortness of breathDizzinessHeadacheAbdominal pain
Are you currently taking any medications? YesNo
Have you had any previous skin conditions? YesNo
Have you had any skin surgeries or procedures? YesNo
Are you currently taking any medications that may affect your skin? YesNo
Do you have a history of skin conditions, such as psoriasis, eczema, keloid, or skin cancer? YesNo
Do you have a history of bleeding disorders or take anticoagulant medications? YesNo
What is the reason for your visit today?
How long have you been experiencing symptoms?
Have you tried any treatments or medications for this condition? YesNo
Social History:
Do you smoke? YesNo
Do you consume alcohol? YesNo
Do you exercise regularly? YesNo
What is your occupation?
I hereby consent to the collection and use of my medical history for the purpose of receiving medical treatment at this clinic. I understand that my information will be kept confidential and secure.
Signature
Date
