New Patient Form

Date

PATIENT NAME:

Last Name:

First Name:

Middle Name:

Date of Birth:

ADDRESS:

Street:

Apt/Unit:

City:

State:

Zip Code:

Marital Status:

Sex:

Male Female

PHONE:

Primary:

Secondary:

Email Address:

Race (Please select all that apply):

African American

Asian

Caucasian

Native American

Pacific Islander

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Preferred Language:

Employer:

Occupation:

Name of Primary Care Physician:

Add physician

Have you seen a dermatologist before? If so please list name(s) below:

Add dermatologist

Preferred Pharmacy Address:

Preferred Pharmacy Phone Number:

EMERGENCY CONTACT:

Name:

Phone:

Relationship:

Address:

Insurance:

ID:

Group:

Subscriber Name:

Date of Birth:

Relationship:

Self Spouse Child

Past Medical History:

Other:

Past Surgical History:

Other:

Skin Disease History:

Other:

Do you wear Sunscreen?

Yes No

If yes, what SPF?

Do you tan in a tanning salon?

Yes No

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Medications:

(Please enter all current medications)

Add medication

Allergies:

(Please enter all allergies)

Add allergy

Social History:

(Please select 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

EtOH -1-2 drinks per da

EtOH -3 or more drinks per day

Other:

Family History

(Only first degree relatives)

Review of Systems:

Are you currently experiencing any of the following?

(Please select yes or no for the following)

Fevers

Yes No

Chills

Yes No

Nausea

Yes No

Vomiting

Yes No

Diarrhea

Yes No

Constipation

Yes No

Chest Pain

Yes No

Shortness of Breath

Yes No

Cough

Yes No

Headaches

Yes No

Numbness

Yes No

Joint Pain

Yes No

Changes in Vision

Yes No

Unintended weight loss

Yes No

Anxiety

Yes No

Depression

Yes No

Easy Bruising

Yes No

Bleeding

Yes No

Painful Urination

Yes No

Other Symptoms:

ALERTS:

Are you pregnant or currently trying to get pregnant?

Yes No

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