MEDICAL HISTORY Today’s Date:______________
Name:________________________________________________________ Date of Birth:_____/______/__________
Height:_________________ Weight:________________ Primary Care Provider: ____________________________________
Reason for your visit today: ________________________________________________________________________________
Duration:__________________________ Location:_____________________________ Any Pets?:
□ No □ Yes
Symptoms: _____________________________________________________________________________________________
Has this condition changed over time?
□ No □ Yes If yes, how? _______________________________________________
Any past treatment?
□ No □ Yes If yes, what treatment/medication?___________________________________
Any response to treatment?
□ No □ Yes If yes, what? ______________________________________________________
Are you al ergic to any medications? □
No □ Yes If yes, list:
1.___________________________________ 2.________________________________ 3._______________________________
Reaction to allergy:
1.___________________________________ 2.________________________________ 3._______________________________
List al medications you are currently taking and dosage (follow-up patients: if any new medications, please list):

1.___________________________________ 2.________________________________ 3._______________________________
4.___________________________________ 5.________________________________ 6._______________________________
Do you now, or have you ever had any of the fol owing diseases or conditions?
(Please check if self or family member)
List any surgeries you have had:

Do you drink alcohol? □ No □ Yes If yes, ___________drinks per day
Do you bleed easily? □ No □ Yes
Do you smoke?
□ No □ Yes If yes, ___________packs per day For how many years? ___________________
Have you been exposed to HIV? □ No □ Yes Women, are you pregnant or nursing? □ No □ Yes
Have you ever had dental anesthesia (Xylocaine)? □ No □ Yes Any bad reaction? □ No □ Yes
When exposed to sun, do you: □ Tan Only □ Tan and Burn □ Burn Do you, or have you ever used a tanning bed? □ No □ Yes
Do you have a history of any specific skin diseases? □ No □ Yes If yes, please list: _________________________________
Preferred Pharmacy and location: _________________________________ Phone: ___________________________________
Patient/Guardian Signature_______________________________ Provider’s Signature: _______________________________

Source: http://www.midatlanticskinsurgery.com/documents/MedicalHistoryautofill.pdf

Patient information leaflet

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Microsoft word - testimonialcomb.doc

Testimonial by Dr Anil Kumar (Swami Shantananda) M.D., D.C.H. Kriyayoga Research Institute, Jhunsi, Allahabad, U.P., India I , a U.S. citizen and a medical doctor, has specialized in the care of children and young adults for the last 38 years. After practicing modern medicine mostly in the United States of America and also in England and India, I have returned to India

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