PAST MEDICAL HISTORY

SKIN:

SYMPTOMS YES NO REMARKS

Have you experienced any pain or

itching in your skin?
Are you currently experiencing any
skin problems such as rashes,
lesions, dryness, bruises, abrasions,
or pigmented spots?
Can you tell me about any previous
experiences with skin issues?
Is there a history of skin problems,
including skin cancer, among your
family members?
Have you ever had allergic reactions
to medications, lotions, or home
remedies?
Do you notice any association of
your skin issues with seasons of the
year?

Related systemic conditions?

Excessively dry or moist feel to the
skin?

Tendency to bruise easily

HAIR:

SYMPTOMS YES NO REMARKS

Recent use of hair dyes, rinses, or
curling or straightening preparations
Recent chemotherapy?
Presence of disease
NAILS:

SYMPTOMS YES NO REMARKS

Have you ever been diagnosed
with diabetes mellitus?
Peripheral Circulatory Disease?
Previous Nail Injury
Undergone severe illnesses in the
past?
SKULL AND FACE:

SYMPTOMS YES NO REMARKS

Have you ever any past problems
with lumps are bumps itching,
scaling, or dandruff?
History of loss consciousness,
dizziness, seizures, headaches a
facial pain or injury
when and how any jumps occurred?
Length of time any other problem
existed any known cause of problem
associated symptoms, treatments,
and recurrence.
NECK:

SYMPTOMS YES NO REMARKS

Have you experienced any
problems with neck lumps?
Do you often have neck pain or
stiffness?

Can you recall when and how any

lumps occurred?

Have you ever been diagnosed

with thyroid problems in the past?

Have you undergone any

treatments such as surgery or
radiation for neck-related issues?