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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