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Name: ________________________ Date of Birth: ____________ Account #_____________Preferred Pharmacy: __________________________________ Location: _________________________Family Physician: _____________________________ Referring Physician: _________________________PAST MEDICAL HISTORY (please check all that apply)□ Anxiety□ Colon Cancer□ Hepatitis □ Prostate Cancer□ Arthritis□ COPD□ Hypertension □ Radiation Treatment□ Asthma□ Coronary Artery Disease□ HIV/AIDS □ Seizures□ Atrial fibrillation□ Depression□ Hypercholesterolemia □ Stroke□ Bone Marrow Transplant□ Diabetes□ Hypothyroidism □ Other□ BPH (benign prostatic□ End Stage Renal Disease□ Leukemia ________________ Hyperplasia)□ GERD□ Lung Cancer ________________□ Breast Cancer□ Hearing Loss□ Lymphoma □ NonePAST SURGICAL HISTORY □ Appendix (appendectomy)□ Liver: Hepatectomy□ Bladder (cystectomy)□ Liver: Transplant□ Breast Biopsy□ Liver: Shunt□ Breast Lumpectomy (both)□ Ovaries: Endometriosis□ Breast Lumpectomy (left)□ Ovaries: Ovarian Cancer□ Breast Lumpectomy (right)□ Ovaries: Ovarian Cyst□ Breast Mastectomy (both)□ Ovaries: Tubal Ligation□ Breast Mastectomy (left)□ Pancreas: Pancreatectomy□ Breast Mastectomy (right)□ Prostate: Biopsy□ Colon (colectomy) Colon Cancer Resection□ Prostate: Cancer□ Colon (colectomy) Diverticulitis□ Prostate: Transurethral Resection (TURP)□ Colon (colectomy) Inflammatory Bowel□ Rectum: Abdominal Perineal Resection (CAPR)□ Colon: Colostomy□ Rectum: Low Anterior Resection □ Gallbladder (cholecystectomy)□ Skin: Basal Cell Carcinoma□ Heart Biological Valve Replacement□ Skin: Melanoma□ Heart: Coronary Artery Bypass□ Skin: Squamous Cell Carcinoma□ Heart: Heart Transplant□ Spleen: Splenectomy□ Heart: Mechanical Valve Replacement□ Testicles: Orchiectomy□ Heart: PTCA (angioplasty)□ Uterus: (hysterectomy) Fibroids□ Joint Replacement: Hip (both)□ Uterus: (hysterectomy) Uterine Cancer □ Joint Replacement: Hip (left)□ Uterus: (Hysterectomy) Cervical Cancer□ Joint Replacement: Hip (right)□ Other: _______________ _________________□ Joint Replacement: Knee (both□ None□ Joint Replacement: Knee (left) □ Joint Replacement: Knee (right) □ Kidney: Biopsy □ Kidney: Nephrectomy □ Kidney: Stone Removal □ Kidney: Transplant Name: ________________________SKIN DISEASE HISTORY□ Acne□ Dry Skin□ Precancerous Moles□ Acne Keratosis □ Eczema□ Psoriasis (Pre-Skin Cancer)□ Flaking or Itchy Scalp□ Squamous Cell Carcinoma□ Basal Cell Carcinoma□ Melanoma□ Other _______________ ________________□ Blistering Sunburns□ Poison Ivy□ NoneDo you wear sunscreen? □ Yes □ No If yes, what SPF? ____________Do you use a tanning salon? □ Yes □ NoFamily history of melanoma? □ Yes □ No If yes, relative: _______________________Medications (list all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements: Medication Name Dosage Frequency Route________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Drug Allergies: _____________________________________________________________SOCIAL HISTORYTobacco Products: □ Current every day smoker □ Former every day smoker □ Never Date Started/Quit _________ Alcohol:□ Less than 1 drink/day □ 1-2 drinks daily □ 3 or more drinks dailyHow many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? ____________Have you ever tested positive for TB? □ Yes □ NoName: ________________________REVIEW OF SYMPTOMS (history or current problem with any of the following? Please check all that apply)Problems with bleeding?□ Yes □ NoWheezing □ Yes □ NoProblems with healing? □ Yes □ No Red Eye □ Yes □ NoProblems with scarring? □ Yes □ NoTearing □ Yes □ NoEye Pain □ Yes □ No Abdominal Pain□ Yes □ No Uncontrolled Blood Pressure □ Yes □ No Anxiety□ Yes □ No Elevated Blood Sugar □ Yes □ NoBloody Stool□ Yes □ No Allergy to adhesives □ Yes □ NoBloody Urine□ Yes □ No Allergy to Lidocaine □ Yes □ NoBlurry Vision□ Yes □ No Allergy to topical antibiotic ointment □ Yes □ NoChest Pain□ Yes □ No Artificial Heart Valves □ Yes □ No Cough□ Yes □ No Artificial joints in the last 2 years □ Yes □ NoDepression□ Yes □ No Blood thinners □ Yes □ NoDizziness□ Yes □ No Defibrillator □ Yes □ NoFever/Chills□ Yes □ NoMRSA □ Yes □ NoGrey discoloration of skin□ Yes □ No Pacemaker □ Yes □ NoHay Fever□ Yes □ No Currently pregnant Headaches□ Yes □ No or planning pregnancy □ Yes □ NoImmunosuppression□ Yes □ NoPremedication prior to procedure □ Yes □ No Joint Aches□ Yes □ NoRapid heartbeat w/epinephrine □ Yes □ No If yes, what year ______Muscle Weakness□ Yes □ NoNeck Stiffness□ Yes □ NoLatex Allergy: □ Yes □ NoNight Sweats □ Yes □ NoRashes/Hives □ Yes □ NoSeizures□ Yes □ NoShortness of Breath □ Yes □ NoSleeplessness □ Yes □ NoSore Throat □ Yes □ NoThyroid Problems□ Yes □ NoUnintentional Weight Loss□ Yes □ No_____________________________________________________________Signature of Responsible PartyDate ................
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