Patient Information
Last Name First Name Middle Initial
Address
City State Zip
Home # ( ) Cell # ( )
Work # ( ) SS #
Email Address
Date of Birth
Sex M F
Marital Status
Single Married Divorced Widowed
Race Ethnicity
Hispanic or Non-Hispanic Prefered Language
If Married, spouse's Name Patient's Employer
Address
City State Zip
Guarantor Information
Relationship to patient If self, do NOT fill out information in this section.
Type of insurance?Last Name
Address / First Name / Middle Initial
City / State / Zip
Date of Birth / Guarantor's SS #
Home # ( /
) / Cell # / ( )
Employer
Address
City / State / Zip
Patient Medical History
Please check ALL that apply to your health
⃝Anxiety / ⃝Hearing Loss
⃝Arthritis / ⃝Hepatitis
⃝Asthma / ⃝HIV/AIDS
⃝Atrial Fibrillation / ⃝Hypercholesterolemia
⃝BPH / ⃝Hypertension
⃝Breast Cancer / ⃝Hyperthyroidism
⃝Colon Cancer / ⃝Hypothyroidism
⃝COPD / ⃝Inflammatory Bowel Disease
⃝Coronary Artery Disease / ⃝Leukemia or Lymphoma
⃝Depression / ⃝Lung Cancer
⃝Diabetes / ⃝Prostate Cancer
⃝End Stage Renal Disease / ⃝Previous Radiation Treatment
⃝GERD / ⃝Seizures
⃝Stroke
Surgery History
⃝Appendix / ⃝Heart Valve Replacement
⃝Breast Cancer / ⃝Hysterectomy
Left, Right or Both / ⃝Joint Replacement
Mastectomy or Lumpectomy / Hip or Knee
⃝Breast Implants / Left, Right or Both
⃝Colon Resection / ⃝Kidney Transplant
⃝Gallbladder (Cholecystectomy) / ⃝Skin Cancer Excision
⃝Coronary Artery Bypass Surgery / ⃝Tonsils
⃝Other
Skin Disease History
⃝Acne / ⃝Flaky or Itchy Scalp
⃝Actinic Keratoses / ⃝Melanoma
⃝Basal Cell Skin Cancer / ⃝Poison Ivy
⃝Blistering Sunburns # / ⃝Pre-cancerous Moles
⃝Dry Skin / ⃝Psoriasis
⃝Eczema / ⃝Squamous Cell Skin Cancer
Reason for Visit
Social History Details
⃝Are you pregnant ⃝ Do you smoke
pks/day
⃝Are you trying to get pregnant ⃝Do you use sunscreen / SPF #
⃝Do you have a family history of melanoma ⃝Do you tan in a tanning bed? If so, how are they related? If so, how often?
Current Medications
Are you allergic to any medications?
Additional Medical Information
⃝ Newspaper
⃝ Yellow Pages
⃝ Hospital Referral
Who may we thank for your referral?
⃝ Friend/Relative Name:
⃝ Other
Pharmacy Name
Address City State
Phone ( )
Thank you for using for all of your skin care needs!Check All That Apply
Immunosuppression / Yes / No
Fever or Chills / Yes / No
Night Sweats / Yes / No
Unintentional Weight Loss / Yes / No
Blurry Vision / Yes / No
Sore Throat / Yes / No
Thyroid Problems / Yes / No
Bloody Stool / Yes / No
Bloody Urine / Yes / No
Problems with Bleeding / Yes / No
Rash / Yes / No
Problems with Healing / Yes / No
Problems with Scarring (hypertrophic or keloid) / Yes / No
Joint Aches / Yes / No
Muscle Weakness / Yes / No
Headaches / Yes / No
Seizures / Yes / No
Anxiety / Yes / No
Depression / Yes / No
Shortness of Breath / Yes / No
Check All That Apply
Blood thinners / Yes / No
Pacemaker / Yes / No
Rapid heart beat with epinephrine / Yes / No
Pregnancy or planning a pregnancy / Yes / No
Allergy to adhesive / Yes / No
Allergy to lidocaine / Yes / No
MRSA / Yes / No
Allergy to topical antibiotic ointments / Yes / No
Artificial heart valve / Yes / No
artificial joints within past two years / Yes / No
Defibrillator / Yes / No
Premedication prior to procedures / Yes / No