Intake and History Form

Oahu Dermatology LLC

Name:

Date of Birth:

Referring Physician (if any):

PCP:

Email Address:

May we leave detailed messages regarding your health care, services, and appointment reminders on your answering machine?

Yes No

Can we send you emails regarding special promotions?

Yes No

Preferred Pharmacy (example: Long’s Makiki) Name:

What is the reason for your visit today?

Past Medical History

If other, specify:

Past Surgical History

If other, specify:

Skin Disease History

If other, specify:

Do you have a family history of Melanoma?

Yes No

If other, specify:

Do you wear sunscreen?

Yes No

If yes, what SPF?

Use of tanning beds?

Currently

Previously

Never

Medications (list all current medications):

Allergies (please specify your allergy and reaction):

No known drug allergies

Social History

Smoking Status:

Current every day smoker

Current some day smoker

Former smoker

Never

Number of packs per day:

Total years smoking:

Alcohol Intake:

3 or more per day

1-2 per day

1 or less per day

None

Occupation:

Family Medical History (only include immediate family)

Acne

Basal Cell/Squamous Cell Carcinoma

Eczema

Psoriasis

Bleeding Disorders

Other Cancers

If other cancers, specify:

Review of Systems (pertaining to yourself)

Please select YES or NO if you have experienced any of the following within the last 30 days:

Problems with bleeding

Yes No

Problems with healing

Yes No

Problems with scarring (hypertrophic/keloid)

Yes No

Rash

Yes No

Immunosuppression

Yes No

Hay fever

Yes No

Chest pain

Yes No

Fever or chills

Yes No

Night Sweats

Yes No

Unintentional weight loss

Yes No

Thyroid problems

Yes No

Sore throat

Yes No

Blurry Vision

Yes No

Abdominal pain

Yes No

Bloody stool

Yes No

Bloody urine

Yes No

Joint aches

Yes No

Muscle weakness

Yes No

Neck stiffness

Yes No

Headaches

Yes No

Seizures

Yes No

Shortness of breath

Yes No

Wheezing

Yes No

Anxiety

Yes No

Depression

Yes No

Alerts

Allergy to adhesive

Yes No

Allergy to lidocaine

Yes No

Allergy to topical antibiotic ointments

Yes No

Artificial heart valve

Yes No

Artificial joints within past two years

Yes No

Blood thinners

Yes No

Defibrillator

Yes No

MRSA

Yes No

Pacemaker

Yes No

Premedication prior to procedures

Yes No

Rapid heartbeat with epinephrine

Yes No

Pregnancy or planning a pregnancy

Yes No

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