Scott D - First Coast Mohs
Scott D. Warren, MD, PA
First Coast Mohs First Coast Mohs Dermatology Associates of FCM
6890 Belfort Oaks Place 216 Ponte Vedra Park Dr 9905 Old St. Augustine Rd
Jacksonville, FL 32216 Ponte Vedra Beach, FL 32082 Jacksonville, FL 32257
904-296-1313 904-296-1313 904-880-7715
PQRS is the federal program that all providers are required to report in addition to all other information to complete your healthcare visit. Failure to report will lead to penalties imposed by the federal government. Please take a moment and answer the below questions. Thank you.
NAME: ___________________________________________ DATE OF BIRTH: _____________________
History and Intake Form
Past Medical History: (please circle all that apply)
Anxiety
Arthritis
Artificial Heart Valve
Artificial joints
Asthma
Atrial fibrillation
BPH (Benign Prostatic Hyperplasia)
Bone Marrow Transplantation
Breast Cancer
Chemotherapy
Colon Cancer
COPD (Emphysema)
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD (Acid reflux)
Hearing Loss
Hemophilia
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lupus
Lymphoma
Organ Transplant
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
None
Other:_______________________________________________________________________________________________________________________________________________________
➢ Have you had an influenza vaccine in the past 12 months (FLU SHOT)? YES / NO
➢ Have you had a Pneumonia vaccine in the past 5 years (Pneumovax shot)? YES / NO
Past Surgical History: (please circle all that apply)
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
PTCA
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Knee (Right, Left, Bilateral)
Joint Replacement, Hip (Right, Left, Bilateral)
Joint Replacement within last 2 years
Kidney Biopsy
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP
Skin Biopsy
Basal Cell Cancer Surgery
Squamous Cell Carcinoma Surgery
Melanoma Surgery
Spleen Removed
Testicles Removed (Right, Left, Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
None
Other: _________________________________________________________________________
Skin Disease History: (please circle all that apply)
Acne
Actinic Keratosis
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
None
➢ Melanoma
Other: _________________________________________________________________________
Do you wear Sunscreen? YES / NO If yes, what SPF? ________ Do you tan in a tanning salon? YES / NO
List of all Medications /Dosages/ Strength/ Route Taken / (By Mouth, Injection and Topical).
How often you take them? (Please enter all/provide list current medications or write ONE): ____________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________
Allergies: (Please enter all allergies or write NONE):
____________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________
Social History:
➢ Do you drink alcohol? YES/NO IF YES:
a. Have you ever felt you should Cut down on your drinking? YES / NO
b. Have people annoyed you by criticizing your drinking? YES / NO
c. Have you ever felt bad or guilty about your drinking? YES / NO
d. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? YES / NO
➢ Do you smoke or use Tobacco? YES / NO IF YES:
e. Never Smoked
f. Quit: former smoker
g. Smokes less than daily
h. Smokes daily
How often do you exercise? What is your caffeine use?
Once a day Once a day
A few times a week A few times a week
A few times a month A few times a month
Never Never
Family History: Circle the following conditions that are in your immediate family
(Mother, Father, Brother, Sister)
Asthma High Cholesterol Lung Disease
Bleeding Disorders Hypertension Lupus Mental Illness
Diabetes Kidney Disease Thyroid Disease
Heart Disease Liver Disease Seizures
Cancer: ___________________________________________________________
(Please specify which kind)
Race: Language: Ethnicity:
White English Hispanic/Latino
Black/African American Spanish Not Hispanic/Not Latino
Asian Other: ______________ Decline to Specify
American Indian/Native Alaskan
Native Hawaiian/Pacific Islander
Pharmacy: Name:___________________________________ Phone Number: ______________________
Address:___________________________________________ Zip:________________________________
Review of Systems: (Please circle one) Alerts: (Please circle one)
Problems with bleeding Currently Pregnant
Problems with healing Planning on Becoming Pregnant
Problems with scarring NOT APPLICABLE
Problems with rash
NONE
Signature: _______________________________________________ Date: _______________________
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