MARILYN KWOLEK , M.D.

PATIENT HISTORY FORM

Name:
PATIENT HEALTH HISTORY
Please circle the appropriate answer:
1. Have you ever been treated for, or do you have any of the following?
- ulcers, colitis or intestinal disease				yes	no
- tuberculosis or lung disease				yes	no
- heart disease or pace maker				yes	no
- high blood pressure				yes	no
- liver or gall bladder disease				yes	no
- emotional/psychiatric problems				yes	no
- urinary/bladder problems or infections				yes	no
- venereal disease				yes	no
- diabetes				yes	no
- thrombopheblitis or blood clots				yes	no
SOCIAL HISTORY
2. Do you smoke? (If yes, how many packs per day?)				yes	no
3. Do you drink alcohol? (If yes, how much?)				yes	no
4. What soap do you use?			Moisturizer?
5. Have you had a recent operation or accident?				yes	no
If yes, please describe:
6. Have you or any member of your family had:
- asthma				yes	no
- hay fever				yes	no
- hives				yes	no
- eczema				yes	no
- psoriasis				yes	no
- diabetes				yes	no
- skin cancer				yes	no
If any of the above are yes, list relationship to person.
7. Please tell us if you have any new conditions while you are under our care.  If you are pregnant, please check with us regarding your treatment.

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