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? ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download