John W. Tyrone, MD
108 NW 76th Drive Suite A, Gainesville, FL  32607
Tel:(352)332-1150  Fax:(352)332-1044
MEDICAL HISTORY
Date: __________________
Name: _______________________________________________________	Nickname: ___________________
First		 Middle 			Last
Age: ________ 	Sex: Male/ Female  Race:_______________ Height:_____________ Weight:______________
Reason for visit: _______________________________________________________________________________
PAST MEDICAL HISTORY List any medical conditions for which you have been treated:
_____________________________________________________________________________________________
_____________________________________________________________________________________________

PAST SURGICAL HISTORY List any operations, including cosmetic, you have had:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Do you have a history of: (Please check yes/no)
Yes No 		                Yes  No 			              Yes  No 		              Yes  No
□ □ Asthma 		 □ □ Hirsutism			□ □ Hormone Therapy    □ □ Keloid Scars
□ □ Acne		  □ □ Diabetes 	     		□ □ Latex Allergy 	□ □ Fever Blisters
□ □ Bleeding Disorders  	  □ □ GERD/Reflux/Ulcers        	□ □ Liver Disease 	□ □ Immune Disorder
□ □ Blood Clots 	  	  □ □ Heart Disease 	                □ □ Nervous Disorder 	□ □ Skin Diseases
□ □ Breast Disease 	  □ □ Lupus Erythematosus             □ □ PCOS 		□ □ Permanent Makeup
□ □ Burn/Skin Grafts 	  □ □ Hepatitis 	     		□ □ Thyroid Disease 	□ □ Metal Implants
□ □ Cancer 		  □ □ High Blood Pressure 	□ □ Tuberculosis 	□ □ Chronic headaches
□ □ Contact Dermatitis      □ □ Hypoglycemia 	    	□ □ Seizures 		□ □ Lupus
□ □ Depression 	  	  □ □ Shingles			□ □ Psoriasis		□ □ Precocious Puberty
□ □ Endocrine Disorder	  □ □ Kidney Disease 	                □ □ Herpes 		□ □ Pacemaker
□ □ Fibromyalgia 	  □ □ Sinus 		                □ □ Vitiligo		□ □ Mitral Valve Prolapse

Please list all MEDICATIONS and dosage recently or regularly taken (include herbal and vitamins):
_____________________________________________________________________________________________
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Please list all ALLERGIES to any medications:_________________________________________________________
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Please list any NON-MEDICATION ALLERGIES (i.e. latex, seasonal, topical products):_________________________
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WOMEN’S HEALTH
Have you ever been pregnant: _______________How many times: ___________ How many deliveries: __________
How many children do you have:   _______ Did you breastfeed: Yes / No When did you stop: ___________________
Is there a possibility that you are currently pregnant or are you actively trying to get pregnant? Yes/ No
Date of most recent MAMMOGRAM: __________________ Results: ____________________
Liposuction / tummy tuck patients: Are you at your goal weight? Yes / No Interested in weight loss program? Yes / No

SOCIAL HISTORY
Have you ever regularly smoked cigarettes / tobacco?  YES/ NO If yes, how many packs per day? _______________
How many years did you smoke? __________________ 	When did you stop smoking? ___________________
Alcohol Use:    	None    /    Occasionally     /    Daily 		History of Drug  use:______________
Exercise: 	None   /    Occasionally     /    Daily 		Diet  Pills:_______________________

Have you used Accutane in the last 6 months? Yes / No   If yes, how recently?__________________________ 
Have you had a chemical peel or facial within the last six months? Yes / No
Have you had any previous laser treatment or other skin treatments to the area being treated? Yes / No
	If yes, what have you had done and how long ago? __________________________________________________ 
Are you currently using or have used a tanning bed or sunless tanners? Yes/ No If yes, how long ago?__________________
Has the area being treated been exposed to the sun within the last four to six weeks? Yes/ No
Are you or have you ever used (please circle): Azelex/ Differin/ Renova/ RetinA/ Tarazac/ Glycolic or AHA acids
Please list the skin care products which you are currently using: ______________________________________________
___________________________________________________________________________________________________
Have you had any permanent cosmetic tattooing in the area to be treated? Yes/ No 			
Have you or anyone in your family ever had unusual reactions to anesthesia 
Including muscle weakness, jaundice, breathing problems, or unexpected fevers?   Yes/ No
Do you have metal implants in your body?  Yes/ No  							
If yes, where?_____________________________________________________   
Do you have any of the following? (Please circle) Loose or chipped teeth/ caps/ dentures/ contact lenses/ piercings
Have you ever seen a cardiologist?  Yes/  No                                                                                
Physician name:  ________________________________________   Date of last EKG: _____________________ 
Do you bruise easily or bleed excessively? Yes/  No                                                                                                                               
Have you ever had a blood clot in your legs or lungs (DVT or pulmonary embolism)? Yes/ No			 
Do you have thickening of scars or keloids following injury or surgery?  Yes/ No						
Have you ever had any weakness of the face or drooping of any part of the face?  Yes/ No			 
Have you ever had "dry eyes" or eye infections?  Yes/ No							 
Have you ever had fainting spells, seizures, blackouts, TIA’s, or strokes? Yes/ No					 
Do you have any neck problems or arthritis?  Yes/ No								 
Do you have any problems with motion sickness or nausea after anesthesia?    Yes/ No				 
Have you ever received a blood transfusion?  Yes/ No								 
Do you have any infectious diseases?  Yes/ No									 
Have you ever seen a psychiatrist?   Yes/ No                                   							
Are you allergic to any antibiotic ointments or skin care products?   Yes/ No					
If yes, please list the medication and reaction:   _____________________________________________________________
____________________________________________________________________________________________________
 
FAMILY HISTORY Please list any illnesses that run in your family: _______________________________________________
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Best contact number: _________________________________       May we leave a message?   Yes / No 		 
Patient’s Signature:  ______________________________________  Date: ________________________