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*:

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