DermSurgery Associates
6700 W. Loop South, Suite 500
Bellaire, TX 77401
Phone: (713) 791-9966
Monday–Friday: 8 a.m.–5 p.m.
Friday: 8 a.m.–4 p.m.

Medical History Form

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Contact Information

Medical Information

Was there any previous treatment?



Was a biopsy done?



Allergies



Medications



Aspirin



Blood Thinners



System Review

(Check all that apply regarding your health and add any other important problems.)

Are you pregnant?



Skin

Kidney

Constitutional Symptoms


Eyes/Ears/Nose/Throat


Respiratory


Gastrointestinal


Musculoskeletal


Neurological


Hematologic/Lymphatic



Endocrine


Cardiovascular







Infections



Past History

Previous Skin Cancer



Major Illnesses or Surgeries



Family History

Skin Cancer



Social History

Smoker



Alcohol



Alcohol or Drug Problems



Do you wear


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