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DERMATOLOGY PATIENT HISTORY FORM DR. RIDER BRUNSWICK MEDICAL GROUP, INC. Name:Age:Date of Birth:Legal Guardians Name (if patient under age 18): Referring Physician (if applicable): Primary Care Physician
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How to fill out dermatology patient history form
How to fill out dermatology patient history form
01
Before filling out the dermatology patient history form, gather all necessary information such as personal details, medical history, and current medications.
02
Start by providing basic personal information such as name, age, gender, contact details, and address.
03
Next, write down any known allergies or sensitivities to medications, environment, or substances.
04
List any existing medical conditions you have, such as diabetes, high blood pressure, or autoimmune disorders.
05
Include a detailed history of previous dermatological conditions or diseases you have experienced.
06
Indicate any previous surgeries or procedures you have undergone for dermatological issues.
07
Provide information about any current medications, topical creams, or treatments you are using for your skin.
08
Answer questions regarding your lifestyle habits, such as exposure to sunlight, tobacco or alcohol use, and diet.
09
Include information about any family history of skin conditions, such as eczema, psoriasis, or skin cancer.
10
Finally, sign and date the form to confirm the accuracy of the information provided.
Who needs dermatology patient history form?
01
Dermatology patient history forms are needed by individuals who are seeing a dermatologist for the first time or for a new skin condition.
02
Anyone seeking dermatological evaluation or treatment can benefit from filling out a patient history form to provide important information to the healthcare provider.
03
Patients with prior or existing skin conditions, allergies, or known dermatological issues are particularly in need of filling out the dermatology patient history form.
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