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