Marietta Dermatology | The leading dermatology provider in ...



Patient Intake FormForms must be filled out completely!Past Medical History: (please circle all that apply)Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow TransplantBreast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing LossHepatitis High Blood Pressure HIV/AIDSThyroid ProblemsLeukemiaLung Cancer Lymphoma Prostate Cancer Radiation TreatmentSeizuresStrokeNoneOther:_____________________________ ___________________________________________________________Past Surgical History: (please circle all that apply)Appendix Removed Joint Replacement within last 2 yearsBladder Removed Kidney Biopsy (Nephrectomy)Mastectomy (Right, Left, bilateral) Kidney Removed (Right, Left)Lumpectomy (Right, Left Bilateral) Kidney Stone RemovalBreast Biopsy (Right, Left, Bilateral) Kidney TransplantBreast Reduction Ovaries Removed: EndometriosisBreast Implants Ovaries Removed: CystColectomy: Colon Cancer Resection Ovaries Removed: Ovarian CancerColectomy: Diverticulitis Prostate Removed: Prostate CancerColectomy: IBD Prostate BiopsyGallbladder Removed TURP (Prostate Removal)Coronary Artery Bypass Spleen RemovedMechanical Valve Replacement Testicles Removed ( Right, Left, Bilateral)Biological Valve Replacement Hysterectomy: FibroidsHeart Transplant Hysterectomy: Uterine CancerJoint Replacement, Knee (Right, Left, Bilateral) Joint Replacement Hip (Right, Left, Bilateral) NoneOther:________________________________________________________________________________________Skin Disease History:( please circle all that apply)Acne Dry Skin Poison IvyActinic Keratoses Eczema Precancerous MolesAsthma Flaking or Itchy Scalp PsoriasisBasal Cell Cancer Hay Fever/ Allergies Squamous Cell CancerBlistering Sunburns Melanoma NonePatient Intake FormDo you wear Sunscreen? Yes NoIf yes, what SPF?_________________Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, whichRelative(s)?_______________________________________________________________________________Medications: ( Please enter all current medications with strength and how often you take it)________________________________________________________________________________________________________________________________________________________________________________________________________________________I authorize Marietta Dermatology and the Skin Cancer Center to retrieve my medication history through their prescribing system and then import it into my electronic record _________________________ Patient SignatureAllergies( Please enter all allergies)Social History: ( Please circle all that apply)Cigarette Smoking: Alcohol Use:Currently Smokes Do not drink alcoholHas smoked in the past Less than 1 drink per dayNever Smoked 1-2 drinks per dayFormer Smoker 3 or more drinks per day If you were or are a smoker: When did you start?____________________Quit:______________How manyPacks/day:__________________How many Years:_______________________________________________If you drink alcohol: Men: How many times in the past year have you had 5 or more drinks in one day?_____Women and anyone over 65 yrs: How many times in the last year did you have 4 or more drinks in one day?_______Family History: ( only first degree relatives)__________________________________________________________________________________________________________________________________________________________________________________________Height:____________ Pharmacy:_______________________Weight:__________ Address/Phone:___________________ ________________________________Best way to contact you:______Cell phone ____Home Phone____Work Phone _____EmailWho is your PCP (Primary Care Physician):______________________________________________________Phone Number:_____________________ Address:_______________________________________________Did a physician refer you today? If so, who?_____________________________________________________Patient Intake FormReview of Systems: Are you currently experiencing any of the following?(Please circle yes or no for the following)Swollen Lymph NodesYesNoFeeling Ill or not feeling well in generalYesNoProblems with bleedingYesNoProblems with healing YesNoProblems with scarringYesNoRash/Other skin IssuesYesNoImmunosuppressionYesNoFever or chillsYesNoUnintentional weight lossYesNoBlurry vision/Visual ChangesYesNoAbdominal painYesNoHeadachesYesNoCoughYesNoShortness of breathYesNoWheezingYesNoAnxietyYesNoMuscles weaknessYesNoDepressionYesNoHay feverYesNoJoint achesYesNoChest PainYesNoSore throatYesNoNight sweatsYesNoNeck stiffnessYesNoThyroid problemsYesNoDiarrheaYesNoAlerts: (please circle all that apply) Allergy to Adhesive Allergy to Lidocaine Allergy to topical antibiotics Allergy to Latex Allergy to IodineArtificial joint replacement Artificial heart valve Require antibiotics prior to surgical procedureAllergy to oral antibioticsBlood thinnersHistory of fever blistersHIV/AIDSHepatitis BHepatitis CMRSARapid heartbeat with epinephrineNeurostimulator/implantable deviceSeizuresKidney diseaseC-DiffPregnant or currently trying to get pregnantOther drug AllergiesPacemakerDefibrillator ................
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