Dermatologist Seattle, WA | Everett Medical Dermatology
New Patient History and Intake FormDate: _____________ Full Name: ____________________________________________ Date of Birth: ______________Past Medical History: (please circle all that apply)ArthritisAsthmaAtrial fibrillation Breast CancerCoronary Artery Disease (Heart Disease)DiabetesEnd Stage Renal Disease (Kidney Disease)Hepatitis (A / B / C)High Blood pressure HIV/AIDSHigh Cholesterol Hypothyroid or HyperthyroidLeukemiaLymphomaRadiation TreatmentSeizuresStrokeNONEOther (circle all that apply or list below):Autoimmune Disorders Bleeding Disorders Cold Sores on Lips Keloid Formation Scleroderma __________________________________________________________________________________________________Past Surgical History: ____________________________________________________________________________________________________________________________________________________________________________________________________Skin Disease History: (please circle all that apply)Basal Cell Skin CancerBlistering SunburnsMelanomaPrecancerous MolesSquamous Cell Skin CancerNONEDo you wear Sunscreen? YesNoDo you tan in a tanning salon? YesNoDo you have a family history of Melanoma?YesNoIf yes, which relative(s)? ______________________________________________________________________________Medications: (Please enter all current medications)______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Allergies: (Please enter all allergies)__________________________________________________________________________________________________Please complete back side of this form →For Internal Use OnlyINCIDENT TOYES / NOMD PROVIDER:_____________PAYES / NOFSE3 6 12REVIEWYES / NOSocial History: (Please circle all that apply)Cigarette Smoking: now previously neverAlcohol Use: none # of drinks a day: _____________For patients 65 and older: Have you received a pneumonia vaccination? Yes NoFamily History of any Medical Conditions (Only first degree relatives):____________________________________________________________________________________________________________________________________________________________________________________________________Preferred Language: _______________________Race:______________________ Ethnic Group:____________________(Requirements of the Healthcare Reform Law)Preferred pharmacy Name: ___________________________ Phone#: ________________ City or Zip code:___________Primary Care Physician: _________________________________ Referring Physician: ____________________________Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following)SymptomYesNoSymptomYesNoWeight lossShortness of breathDepressionChest painMuscle achesEasy bruisingJoint painBlood clotsFeverSwollen lymph nodesOther Symptoms: ____________________________________________________________________________________________________________________________________________________________________________________________________ALERTS: (please circle all that apply)Allergy to Adhesive or latexAllergy to local anestheticsAllergy to topical antibioticsArtificial heart valveArtificial joint replacementBlood thinnersDefibrillator MRSAPacemakerRequire antibiotics prior to a dental or surgical procedureRapid heart beat with epinephrine Are you pregnant or currently trying to get pregnant?Are you currently breastfeeding? ................
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