American Medical Center UAE
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Patient History Questionnaire Dermatology
Name
Email
Date of Birth
Do you have any allergies?
Yes
No
Have you had any surgeries?
Yes
No
Do you have any medical conditions?
Diabetes mellitus
Hypertension
Heart disease
Asthma
COPD
Cancer
Thyroid problem
N/A
Have you experienced any of the following symptoms in the past 6 months?
Chest pain
Shortness of breath
Dizziness
Headache
Abdominal pain
N/A
Are you currently taking any medications?
Yes
No
Have you had any previous skin conditions?
Yes
No
Have you had any skin surgeries or procedures?
Yes
No
Are you currently taking any medications that may affect your skin?
Yes
No
Do you have a history of skin conditions, such as psoriasis, eczema, keloid, or skin cancer?
Yes
No
Do you have a history of bleeding disorders or take anticoagulant medications?
Yes
No
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?
Yes
No
Social History:
Do you smoke?
Yes
No
Do you consume alcohol?
Yes
No
Do you exercise regularly?
Yes
No
What is your occupation?
Signature
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.
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