Common use of Medical History Clause in Contracts

Medical History. Patient Name: Date: / / What skin issue are you here for: Are you ALLERGIC to LATEX? YES NO If Yes, explain reaction: Have you ever had a SKIN CANCER? YES NO If YES, Circle Type: MELANOMA BASAL CELL CARCINOMA SQUAMOUS CELL CARCINOMA Is there a FAMILY HISTORY of MELANOMA: YES NO Who? Is there a FAMILY HISTORY of Other SKIN CANCER : YES NO Who? Have you ever been diagnosed with HIGH BLOOD PRESSURE (hypertension) or DIABETES? : YES NO Are you taking ASPIRIN, MULTI-VITAMINS, FISH OIL or HERBAL SUPPLEMENTS?: YES NO Do you currently use Nicotine? YES NO How many yrs? Tobacco Vaping electronic pen Are you ALLERGIC to any medicines? YES NO If Yes, please list: MEDICATION ALLERGY REACTION MEDICATIONS and SUPPLEMENTS/HERBALS you are currently taking : NONE