Patient History Form

Name:

Date:

Age:

Reason for today’s visit:

Check up Other

Other:

Other Important Medical History:

If you checked Breast, Mastectomy:

Right

Left

Bilateral

If you checked Joint Replacement, Hip:

Right

Left

Bilateral

If you checked Breast, Lumpectomy:

Right

Left

Bilateral

If you checked Kidney Removed:

Right

Left

If you checked Breast Biopsy:

Right

Left

Bilateral

If you checked Testicles Removed:

Right

Left

Bilateral

If you checked Joint Replacement, Knee

Right

Left

Bilateral

Other Important Surgical History:

If Other, please specify:

BCC or SCC: Year:

Location:

Treatment:

Melanoma: Year:

Depth:

Location:

Treatment:

Do you wear Sunscreen?

Yes No

What SPF?

Have you tanned in a tanning salon?

Yes No

If Yes, at what age was the first time?

Family History:

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Please list primary Local Pharmacy (name, city, zip and phone):

Please list Mail Order Pharmacy (name):

Medications: (Please enter all current medications)

Add medication

Allergies to Medications: (Please enter all medication allergies and reactions):

Social History: (Please choose all that apply)

Smoking Use:

Currently Smokes – daily Currently Smokes - not daily Has never smoked Has smoked in the past

Alcohol Use:

None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day

IV Drug Use:

Other:

May we leave a message at home if you do not answer the phone?

Yes No

Emergency Contact Name:

Relation:

Phone:

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