The Dermatologic Surgery Center of Washington, LLC

Skin Cancer Treatment Center, LLC

Maral Kibarian Skelsey, MD

5530 Wisconsin Ave., Suite # 820

Chevy Chase, MD 20815

Tel #: 301-652-8081 Fax #: 301-652-8627

PATIENT MEDICAL HISTORY FORM

Patient Name: Date of Birth: Today's Date: Referred By: Regular Physician: Occupation: Employer: Sex: Male Female What is the reason for your visit today? When did you notice it? Is it now: Better Worse No Change Drug Allergies (please check and list type of reaction):

No Known Allergies

Anesthetics
Codeine
Penicillin
Tetracycline

Aspirin
Erythromycin
Sulfa
Other Drugs

Non-Drug Allergies:

(include reactions)

Current Medications:

Name / Strength / Dose 1. 2. 3.

Name / Strength / Dose 4. 5. 6.

Do you require Pre-Medication prior to any surgery? No Yes (Describe) For what reason?

MEDICAL HISTORY:

Do you have or have you ever had a history of: (Please check all that apply)

Other Other Other

Females

Chronic vaginal infection
Currently pregnant

Taking oral contraceptives
Possibly pregnant

Nursing
Date of last menstrual period

SURGICAL HISTORY:

	Type of Surgery	Date of Surgery
1.
2.
3.
4.

COSMETIC PROCEDURES:

	Type	Date
1.
2.

SOCIAL HISTORY:

Has your weight changed in the last 6 months? Yes No Loss: lbs Gain: lbs Do you use tobacco? Yes Never Quit If yes, how much per day? How long? Do you use drink alcohol? Yes Never Quit If yes, how much? How often? Do you use recreational drugs? Yes Never Quit If yes, how much? How long? Marital Status: S M W D

FAMILY HISTORY:

Please check if you have a family history of:

Allergies
Arthritis
Asthma

Cancer
Collagen Vascular Disease
Diabetes

Eczema
Hay Fever
Melanoma

Psoriasis
Skin Cancer

OTHER PERTINENT HISTORY:

1. 2. 3. 4.

PHYSICIAN'S NOTES:

Date: Initials: Date: Initials: Date: Initials: