NAME:_________________________________ DATE OF BIRTH
NAME:______________________________________ DATE OF BIRTH:_________________________
History and Intake Form
Past Medical History: (please circle all that apply)
Arthritis Depression High Cholesterol
Asthma Diabetes High Blood Pressure
Atrial fibrillation Hepatitis B or C Seizures
Cancer _________________(type) HIV/AIDS Stroke
Coronary Artery Disease Kidney Disease NONE
Other:_______________________________________________________________________________________________________
Past Surgical History: (please circle all that apply)
Organ Transplant Valve/Joint Replacment NONE
Other:_________________________________________________________________________________________ ______________
Skin Disease History: (please circle all that apply)
Actinic Keratoses Eczema Psoriasis
Basal Cell Skin Cancer Melanoma Squamous Cell Skin Cancer
Blistering Sunburn Atypical Moles NONE
Other:_________________________________________________________________________________________ ______________
Do you have a family history of Melanoma? Yes No
If yes, which relative(s)? __________________________________________________________________________
Medications: (Please enter all current medications)__________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Allergies: (Please enter all medical allergies)___________________________________________________________
_________________________________________________________________________________________________________________
Social History: (Please check one for each question)
Smoker: Language: Race: Ethnicity:
θYES θEnglish θ White θ Asian θ Hispanic/Latino
θNO θOther:_____________________ θBlack/African Amer θNot Hispanic/Latino
θOther θ Decline θDecline
Review of Systems: (please circle all that apply)
Skin disorder Depression Allergy to Medication
Poor Overall Health Cough Blood Thinners
Nausea/Vomiting Chest Pain Pregnant or planning
Joint Aches Bloody Urine Immunosuppression
Bleeding Problems Fever or Chills Organ Transplant
Blurry Vision Mouth Sores Allergy to lidocaine
Headaches Thyroid problems Pacemaker or Defibrillator
Pharmacy: (Name, Address, Phone)_______________________________________________________________
................
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