Keller Skin Care



HISTORY AND INTAKE FORMPatient Name: _____________________________________________________ Date of Birth _____/_____/_____Pharmacy: _______________ Major Cross Streets and/or Phone #: _________________ City, State: ____________Medicare Part B: Yes / No Pneumonia Vaccination: Yes / No Influenza Vaccination: Yes / NoMEDICAL HISTORY (please circle all that apply)AnxietyDepressionHypothyroidism (Low)ArthritisDiabetesLeukemiaAsthmaEnd Stage Renal DiseaseLung CancerAtrial FibrillationGERD (Reflux Disease)LymphomaBone Marrow TransplantationHearing LossProstate CancerBenign Prostatic HypertrophyHepatitisRadiation TreatmentBreast CancerHypertension (High Blood Pressure)SeizuresColon CancerHIV/AIDSStrokeCOPDHypercholesterolemiaCoronary Artery DiseaseHyperthyroidism (High)NONEOther __________________________________________________________________________________________________ SURGICAL HISTORY (please circle all that apply)Appendix RemovedJoint Replacement, HipProstate Removed: Prostate CancerBladder Removed (Right, Left, Both)Prostate: TURPBreast BiopsyJoint Replacement, KneeSkin: Basal Cell Cancer SurgeryLumpectomy (Right, Left, Both) (Right, Left, Both)Skin: Melanoma SurgeryMastectomy (Right, Left, Both)Kidney BiopsySkin BiopsyColectomy: Colon Cancer ResectionKidney Stone RemovedSkin: Squamous Cell Cancer SurgeryColectomy: DiverticulitisKidney TransplantSpleen RemovedColectomy: IBDKidney Removed (Right, Left)Testicles RemovedColostomyOvaries: EndometriosisHysterectomy: FibroidsGallbladder RemovedOvaries: Ovarian CancerHysterectomy: Uterine CancerHeart: Biological Valve ReplacementOvaries: Ovarian CystHysterectomy: Cervical CancerHeart: Coronary Artery BypassOvaries: Tubal LigationHeart: Heart Transplant Pancreas: PancreatectomyHeart: Mechanical Valve ReplacementProstate BiopsyNONEOther ________________________________________________________________________________________SKIN DISEASE HISTORY (please circle all that apply)AcneEczemaPsoriasisActinic KeratosesFlaking or Itchy ScalpSquamous Cell Skin CancerAsthmaHay Fever/AllergiesBasal Cell Skin CancerMelanomaBlistering SunburnsPoison IvyDry SkinPrecancerous MolesNONEOther ________________________________________________________________________________________Do you wear Sunscreen? □ Yes □ No; If yes, what SPF? ________________Do you tan in a tanning salon? □ Yes □ NoDo you have a family history of Melanoma? □ Yes □ NoIf yes, which relative(s)? __________________________________________________ Continued on Back MEDICATIONS & SUPPLEMENTS (If you do not know the name, enter condition and a question mark next to it.)□ I do not take medications and/or supplements.1. ___________________________________7. ___________________________________2. ___________________________________8. ___________________________________3. ___________________________________9. ___________________________________4. ___________________________________10. __________________________________5. ___________________________________11. __________________________________6. ___________________________________12. __________________________________MEDICATION ALLERGIES / REACTION□ No known Allergies.1. ___________________________________4. ___________________________________2. ___________________________________5. ___________________________________3. ___________________________________6. ___________________________________SOCIAL HISTORY (please circle all that apply)Smoking Status:How often do you exercise? Never smoker Never Former smoker Several times a day Current smoker: □ Cigarettes □ Cigars Once a day ● How many packs per day? _________ A few times a week ● How many years smoking? _________ A few times a monthAlcohol Use:Caffeine Use: Alcohol: None Never Alcohol: Less than 1 drink per day Once a day Alcohol: 1-2 drinks per day Several times a day Alcohol: 3 or more drinks per day A few times a week A few times a month□ Retired □ Student □ Occupation: _________________________________________________________ ................
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