Medical History Form

Medical History Form

Name*:
Nick Name:
Address 1:
Address 2:
City:
State:
Zipcode:
Phone:
Cell:
Your Email*:
Date of Birth*:
Employment*:
Phone #:
OK to call?

Primary Physician Name*:
Address:
City:
State:
Zipcode:
Phone #:

Pharmacy Name*:
Phone #:

Primary Insurance*:
Secondary Insurance:

Please list all medications that you take (including all herbal and over the counter)

Surgical Procedures You Have Had:
List Any Diseases Or Medical Conditions:
Allergies To Medications (Name):
Do You Or Any Immediate Family Members Have A History Of:
Melanoma:
If Yes, Whom?:
Basal Cell Or Squamous Cell Skin Cancer:
If Yes, Whom?:
Other Skin Diseases (please list)

Have You Experienced 5 Or More Sunburns?
Have You Ever Used A Tanning Bed?
Did You Spend The First Twenty Years Of Your Life In A Tropical Environment?
Please Check All That Apply:



Any Other Medical Information You Should Share With Us:

Patient Signature*:
Date*: