Close Patient Form Patient Information: Medical History: Please list any medications, vitamins or supplements that you are taking: Have you ever recently discontinued a medication or supplement in the last 4 weeks, including aspirin, advil, or ibuprofen (Motrin): Do you bruise easily?   Y   or    N   Have you ever been allergic to a medication?  Y   or   N  Please List: Do you have any of the following conditions/illnesses? Asthma        Y or N               Hay fever/Sinus Condition Y or N Bleeding disorder  Y or N   Heart disease Y or N Emphysema  Y or N            High Blood Pressure Y or N Diabetes       Y or N             Cancer, If so what type ________ Hepatitis     Y or N              HIV Disease Y or N Arthritis Y or N Have you ever had an HIV test?  Y   or   N Have you ever had surgery?   Y   or   N Please indicate what type: Are you allergic to any form of anesthetic (Novocain or Lidocaine)? Y   or   N Do you smoke?    Y   or   N If yes, how much? Dermatology History: Have you ever had skin cancer?  Y   or   N Has anyone in your family ever had skin cancer?   Y   or   N Do you have any of the following conditions?   Psoriasis       Y or N                   Eczema Y or N Acne Vulgaris   Y or N              Dry Skin  Y or N Hair Loss   Y or N                      Abnormal Nail Growth  Y or N                  As part of your skin examination today a skin cancer screen may be performed. If there are any new moles/spots/growths on the skin please indicate area: