ACADEMIC DERMATOLOGY ASSOCIATES MEDICAL HISTORY FORM 1

NAME:______SEX (circle one): Male Female

Current Medications, Vitamins, Minerals, Supplements, & Herbs

Medication Name / Daily Dose / Start Date / Reason Taking/ Using

Check Box if you list additional medications on a separate page.

Allergy/ Intolerance to Medications, Foods, Animals, or Other

Allergy / Start Date / Type of Reaction
Med. Taken
Med. Taken
Med. Taken

Check Box if you carry epinephrine for an above listed allergy.

Relevant Past Surgeries Date Occurred

Check Box if you have a surgical procedure planned. Surgery Type: ______

Date:______

Birth Control (Both Men & Women) / Start Date
Contraception:

PLEASE CHECK RELEVANT MEDICAL HISTORY (Leave Blank if NOT Applicable)

EYES Start & End Date Details

Glaucoma / Med. Taken Lt. Rt. Both
Cataracts / Med. Taken Lt. Rt. Both
Glasses / Med. Taken

EARS, NOSE, THROAT Start & End Date Details

Hay Fever/ Seasonal Allergies / Med. Taken
Hearing Problems / Med. Taken Lt. Rt. Both
Dental Problems / Med. Taken

ENDOCRINE Start & End Date Details

Diabetes / Med. Taken TYPE: I or II
Thyroid Disease / Med. Taken
Hormonal / Med. Taken

RESPIRATORY Start & End Date Details

Asthma / Med. Taken
Emphysema/ COPD / Med. Taken

NEUROLOGICAL Start & End Date Details

Migraines / Med. Taken
Headaches / Med. Taken
Depression / Med. Taken
Other: / Med. Taken

CARDIOVASCULAR Start & End Date Details

Hearth Attack / Med. Taken
Heart Murmur / Med. Taken
High Blood Pressure / Med. Taken
High Cholesterol/ Lipids / Med. Taken
Angina / Med. Taken

STOMACH/ G.I. Start & End Date Details

Constipation / Med. Taken
Diarrhea / Med. Taken
Heartburn/Indigestion/GERD / Med. Taken
Hepatitis / Med. Taken Type: A B C
Ulcers / Med. Taken

UROGENITAL Start & End Date Details

Kidney Infections / Med. Taken
Bladder Infections / Med. Taken
Kidney Stones / Med. Taken
Prostate Problems(male) / Med. Taken
Menopausual(female) / Med. Taken Date of last period:

HEMATOLOGICAL Start & End Date Details

Anemia / Med. Taken
Other: / Med. Taken

MUSCULOSKELETAL Start & End Date Details

Arthritis / Med. Taken
Gout / Med. Taken
Osteoporosis / Med. Taken
Other: / Med. Taken

SKIN Start & End Date Details

Precancer / Med. Taken
Cancer / Med. Taken
Acne / Med. Taken
Psoriasis / Med. Taken
Rosacea / Med. Taken
Eczema / Med. Taken

OTHER CONDITION Start & End Date Details

Med. Taken
Med. Taken

Do you Smoke?Yes* No *Cigarettes a day:______ Start Date:______

Do you Drink? Yes* No *Drinks a Day:______Start Date:______

I certify that I have completed this form to the best of my knowledge and that it represents all relevant medical conditions that I have/had and includes all prescriptions and over-the-counter medications which I take. I understand that if I fail to provide complete and accurate information, I could be enrolled in a clinical study which might expose me to risk which could otherwise be avoided and I could be discontinued from a clinical trial.

Subject/ Guardian Signature: ______Date:______

ADA Staff Member who Reviewed the Medical History: ______Date:______

Version: 12/27/10