Joseph J. SchwarE, M.D.Dermatology Medical History

Potient: Dote:

Reoson for todoy's visit:

Are you ollergic to ony medicotions?].

E] NO lf yes, list:I] YES

2.

Hove you ever hod dentol onesthesio {Novocoine)? tr YES tr NO Any bod reoction? tr YES tl NO

List oll medicolions you ore currenilyloking (including prescriptions, over-the-countermeds., vitomins, ond herbols):t.2.

3.4.

Do you hove now, or hqve you ever hod diseoses or conditions of: (Pleose check YES or NO)Lungs:

Bronchitis

Emphysemo

Asthmo

Chronic CoughMorning CoughShortness of Breoth

Wheezing

Cordiovosculor:High Blood Pressure

Chest Poin

HeortAttockHeortMurrnurlrregulor HeortbeotPhlebitis

lnflomotion of veinBlood clots

Pocemoker

YES NOtrEIBtrtrtrUEItrtrE] E]utrY-ES

trtrBDtrtrtrtrtr

NOtrEI

truuuEI

Etr

OlherSystemic:Diobetes

Excessive th i rst/h u n g e rThyroid

Kidney

BlodderFrequency/burning

GostrointestinolStomoch obsorptive d isorderNouseo, vomiting, d io rrheo

when toking ontibioiicsYeost infection when

toking ontibioticsArth ritis/Joint Deform ity

ArthrolgioLimited motionA*ificisl ioint

Convulsions, E pilepsy or Seizures

YEs NOtrtrEItrtrEIatrEtrtrn

trutr[]trEltrtrEIurItrtra

trntrtrtrEI

Skin:When you ore exposed to sun do you:Hove you ever hod skin concer?Hos onyone in yourfomily hod skin concer?Do you hove o history of cny specific skin diseoses?If yes, pleose list:

EJ Ton ond burn tl Burn

trNOtr NO If YES, WhO?uNo

Fointing

E Ton onlytr YES

N YES

B YES

Do you develop skin roshes in reoction to E Medicotions E Food tr Environmenl?

List ony other diseoses or conditions:Lisf surgicol procedures you hove hod in the lost 6 months:

Socinl History:Do you drink olcohol?Do you use lV drugs?Do you smoke?

YES I NO lf YES drinks per doyYES tr NO lf YES, whot?YES n NO lf YES, how much:

Hsve you hod or hove you been exposed to HIV (AIDS) ? tI YES tr NO

Pleose o nswer the following questions :

A. Do you bleed eosily?B. (Women) Are you pregnont? Dy* Dote:C. Whot is your occupotion ?

D. Whot ore your hobbies?

Completed by:Signed by Potient

hiti"lt@2002 lnga Ellzey Practice Group, lnc. May be reproduced for personal use only.

trtrtr

How much?

E] YES E] NOE] YES tr NO

tru

PotientMedicol Assistont Dote

Reviewed by Dote

Joseph J. Schwartz, M.D,

Name Date of Birth I I M/t'

Address Age

City State_ Zip

Phone (H)

Emergency Contact: ]rlame

Phone (W)

Phone

Insurancs Information

Co-Pay S

Insurancs Company

ID# Group #

Subscriber of trnsurance Relationship

Date of Birth I I Phone (H)

Secondary Insurancs

ID# Group #

Suhscriber of Insurance Relationship-

Date of Birth I I Phone (H)

Primary l)octor Phone Fax

Address

How did you hear about our practice?

Assignment and release: I hereby authorize my insurance benefits be paid directly to thephysician and acknowledge that I am financially responsible for any unpaid balances. Ialso authorize the physician to release any information required by the insurancecompany, including medical records. I understand that I am financially responsible for allcharges, whether or not covered by insurance.

Signed Date I I