Appointments: (985) 876-5000
Patient Forms

Medical History

* = Required Fields, if you do not have an answer type in "none".
Please be complete and honest. This information is strictly confidential and used only by the Doctor to evaluate and treat your medical condition.
Patient:* DOB*: Age:* Sex*:
Home Phone: Work Phone: Cell Phone:
I hereby authorize the physician or their representative to leave laboratory results on my* (check all that apply)
Home answering machine Work voicemail Cell phone Email
Reason for today’s visit:*  
Referring Physician:* Phone:*
Primary Physician:* Phone:*
General Health: Poor Fair Good Excellent
Are you allergic to any medications? Yes No If yes, list:

List all Medications you are currently taking (please include any prescriptions, over the counter products, vitamins, herbals, etc.)
Past medical history - Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO)
LUNGS: YES     NO   OTHER: YES     NO
Bronchitis         Diabetes      
Emphysema         Thyroid      
Asthma         Kidney      
Chronic/morning Cough         Bladder      
TB (tuberculosis)         Stomach/Bowel      
VASCULAR: YES     NO   Liver/Hepatitis      
High Blood Pressure         HIV/AIDS      
Chest Pain         Arthritis/Joint deformity      
Heart Attack/Stroke         Convulsions, Epilepsy or Seizures      
Heart Murmur         Fainting      
Irregular Heartbeat         Depression/Mental Illness      
Pacemaker/Artific. valve         Lupus      
Phlebitis/blood clots         Glaucoma/Cataracts      
Anemia         Cancer       Type
SKIN
When you are exposed to the sun do you:* Tan, never burn Tan more than burn Burn more than tan Burn, never tan
Have you ever had skin cancer?

Yes No

If yes, what type?
Has anyone in your family had skin cancer? Yes No
If yes, who and what type?
Do you have a history of specific skin diseases? Yes No
If yes, please list
Do you develop keloids (large scars) after injury to the skin? Yes No
Do you bleed/ bruise easily? Yes No  
Do you have problems with poor wound healing? Yes No  
Have you ever had dental or local anesthesia (Novacaine)? Yes No
Any bad reaction? Yes No
Do you have artificial joint(s)? Yes No  
List any other diseases or conditions:
List any surgical procedures you have had in the last 1 year:
Please answer the following questions:  
Do you smoke? Yes No
if yes, how much:
Do you drink alcochol? Yes No
if yes drinks per day  
Do you use IV drugs? Yes No
if yes, what?
How much
What is your occupation?
FEMALE PATIENTS: Date of last menstrual cycle
Are you currently pregnant or could you be pregnant? Yes No Type of birth control
Previous pregnancies  
ALL PATIENTS:

The above information is accurate and complete to the best of my knowledge. I understand that it is my
obligation and responsibility to notify Poole Dermatology of any changes in my medical condition or medications during the course of my medical treatment.
(Name)* (Date)*