PATIENT’S NAME: TODAY’S DATE:
PREFERRED NAME: ______DATE OF BIRTH: SEX:
PRIMARY CARE PROVIDER:
REFERRING PHYSICIAN (If applicable):
OCCUPATION: EMAIL (optional):______
Are you interested in receiving e-mail notifications regarding special events on our cosmetic services & products?
YES NO
1. Briefly describe the problem (with skin, hair, or nails) that brought you in today.
2. How long have you had this problem?
3. What treatments or medications have been tried for this problem?
4. Past Medical History: (please circle all that apply)
Anxiety
Arthritis
Asthma
Atrial fibrillation
Bone Marrow Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
High Blood pressure
HIV/AIDS
High Cholesterol
Thyroid Problems
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
NONE
Other/Description______
5. Please list any surgeries you have had in the past and explain what for: ______
6. Medications: (Please enter all current medications)
______
7. Allergies: (Please enter all allergies)
______
8. ALERTS: (please circle all that apply)
Allergy to Adhesive
Allergy to lidocaine
Allergy to topical antibiotics
Artificial heart valve
Artificial joint replacement
Blood thinners
Defibrillator
MRSA
Pacemaker
Require antibiotics prior to a surgical procedure
Rapid heart beat with epinephrine
9. Skin Disease History: (please circle all that apply)
Acne
Asthma
Hay Fever/Allergies
Dry Skin
Eczema
Precancerous Moles
Squamous Cell Skin Cancer
Basal Cell Skin Cancer
Melanoma
Psoriasis
Blistering Sunburns
Flaking or Itchy Scalp
Poison Ivy
NONE
Other______
10. Do you wear Sunscreen? Yes No If yes, what SPF? ______
11. Do you tan in a tanning salon? Yes No
12. Social History: (Please circle all that apply)
Cigarette Smoking:
Currently Smokes
Has smoked in the past
Never smoked
Former Smoker
Alcohol Use:
EtOH- None
EtOH- less than 1 drink per day (socially)
EtOH -1-2 drinks per day
EtOH -3 or more drinks per day
How many packs per day? ______
13. FEMALE PATIENTS:
a. Are you pregnant or currently trying to get pregnant? ______
b. Breast feeding?
c. Using hormone replacement therapy or using contraception containing hormones (birth control pills,
Mirena IUP, Depo Provera)? If yes, please list:
FAMILY HISTORY
1. Do you have a family history of Melanoma? Yes No
If yes, which relative(s)? ______
2. Do you have a family history of autoimmune disease (such as lupus)?
3. Do you have a family history of eczema? ______
4. Do you have a family history of psoriasis? ______