Post on 19-Apr-2018
Name: _________________________________ DOB: ________________________ Date: ___________________________
Reason for visit: ______________________________________________ How long: ________________________________
Treatments: ___________________________________________________ Symptoms: _______________________________
Past Medical History:
Anxiety Depression Leukemia
Arthritis Diabetes Lung Cancer
Artificial joints End Stage Renal Disease Lymphoma
Asthma Gerd Pacemaker
Atrial fibrillation Hearing Loss Prostate Cancer
BPH Hepatitis Radiation Treatment
Bone Marrow Transplantation High Blood Pressure Seizures
Breast Cancer HIV/AIDS Stroke
Colon Cancer High Cholesterol Valve Replacement
COPD Hyperthyroidism NONE
Coronary Artery Disease Hypothyroidism
Other_______________________________________________________________________________________
Past Surgical History:
Appendix Removed Kidney Biopsy
Bladder Removed Kidney Removed (Right, Left)
Mastectomy (Right, Left, Bilateral) Kidney Stone removal
Lumpectomy (Right, Left, Bilateral) Kidney Transplant
Breast Biopsy (Right, Left, Bilateral) Ovaries Removed: Endometriosis
Breast Reduction Ovaries Removed: Cyst
Breast Implants Ovaries Removed: Ovarian Cancer
Colectomy: Colon Cancer Resection Prostate Removed: Prostate Cancer
Colectomy: Diverticulitis Prostate Biopsy
Colectomy: IBD TURP
Gallbladder Removed Spleen Removed
Coronary Artery Bypass Testicles Removed (Right, Left, Bilateral)
PTCA Hysterectomy: Fibroids
Mechanical Valve Replacement Hysterectomy: Uterine Cancer
Biological Valve Replacement Joint Replacement Knee (Right, Left, Bilateral)
Heart Transplant Joint Replacement Hip (Right, Left, Bilateral)
Other___________________________________________ NONE
Skin Disease History:
Acne Dry Skin Poison Ivy
Actinic Keratosis Eczema Precancerous Moles
Asthma Flaking/Itchy Scalp Psoriasis
Basal Cell Skin Cancer Hay Fever/Allergies Squamous Cell Skin Cancer
Blistering Sunburns Melanoma MOHS Surgery
Other: _______________________
LietN.Le,MD,FAAD22659Hwy59N.Suite140
Kingwood,TX77339P:281-973-4159F:281-973-2359
Do you wear sun screen? Yes or No
If yes, what SPF? ___
Do you tan in a tanning bed?
Family History: Do any of these problems run in the family? (Circle all that may apply)
Malignant Melanoma Dysplastic Nevi (atypical moles) Psoriasis Lupus
If yes, Which relative(s)? ______________________________________________________________________
Cautions: (Circle all that may apply)
Have you ever had difficulty stopping bleeding? Yes / No
Do you require antibiotics prior to a surgical procedure? Yes / No
Have you had an artificial joint replacement? Yes / No
IF yes, when and what body location? ______________________________
Do you have an artificial heart valve? Yes / No
Do you have a pacemaker? Yes / No
Do you have a defibrillator? Yes / No
Are you pregnant or planning to become pregnant? Yes / No
Medications:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Drug Allergies:
_____________________________________________________________________________________________________________________
Preferred pharmacy name, contact & location: _________________________________________________________________
Social History:
SMOKING:
Current smoker Drug use
Former smoker NONE
Other______________________________________________________________________________________________________________
What is your occupation? ______________________________________________
How many times in your life can you estimate having a blistering sunburn? ______________
ALCOHOL:
Do you consume alcohol? Yes / No If yes, How often? ________________________________
Preferred Language: _____________________________
LietN.Le,MD,FAAD22659Hwy59N.Suite140
Kingwood,TX77339P:281-973-4159F:281-973-2359