Welcome - Alamo Oaks Dermatology
Name:__________________________Date:_________Select any of the following medical conditions that you currently have:AnxietyArthritisAsthmaIrregular HeartbeatEnlarged ProstateBone Marrow TransplantationBreast CancerColon CancerEmphysemaCoronary Artery DiseaseDepressionDiabetesEnd Stage Renal DiseaseAcid RefluxHearing LossHepatitisHigh Blood PressureHIV/AIDSHigh CholesterolHigh ThyroidLow ThyroidLeukemia Lung CancerLymphomaProstate CancerRadiation Treatment SeizuresStrokeOther:________________________NonePlease list surgeries you have had:________________________________________________________________________________________________________________________________________________________________________________________Have you had any of the following skin conditions?AcneActinic KeratosesMultiple MolesBasal Cell Skin CancerBlistering SunburnsDry SkinEczemaFlaking or Itchy ScalpHay Fever/AllergiesMelanomaPoison Ivy(Continued)Precancerous MolesPsoriasisSquamous cell skin cancerNoneFamily History of skin cancer: (BCC, SCC)Which family member?___________________________________________Melanoma: yesnomaybe (circle one)Which family member?___________________________________________Do you wear Sunscreen?________If so, what SPF? _________Have you ever tanned in a tanning salon?___________Please list your current Medications:______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please list your Allergies to Medications:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please tell us your social history about:Smoking:Never a smokerFormer smokerCurrently every day smokerOther:______________________________________Alcohol Use:NeverLess than 1 drink per day1-2 drinks per day3 or more drinks per day*Please turn over, form continued on backsideReview of Systems: Check any that apply to you:Problems with bleedingProblems with healingProblems with scarring (hypertrophic or keloid)ImmunosuppressionChanging mole(s)RashAbdominal painAnxietyCoughDepressionFever or chillsHeadachesHay feverJoint achesMuscle weaknessNight sweatsSeizuresShortness of breathThyroid problemsUnintentional weight lossWheezingPacemakerDefibrillatorArtificial joints within past 2 yearsArtificial heart valvePremedication prior to proceduresAllergy to adhesiveAllergy to topical antibiotic ointmentsBlood thinnerPregnancy or planning pregnancyAllergy to lidocaineRapid heartbeat with epinephrineYeast infections with antibioticsGI upset with antibioticsOther:_________________________________________________________________________________NoneWest Africa: Travel or ContactEbola Risk: Fever >= 100.4(F)/ 38 degrees (C)Ebola Risk: Resided or Traveled to country with wide-spread Ebola transmission in the last 21 daysEbola Risk: Contact with an Ebola patient without proper protective equipment within the last 21 daysEbola risk: Headaches, weakness, muscle pain, vomiting, diarrhea, abdominal paid, and/or hemorrhageThank you ................
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