Medical History Form

Appointment Date

Mr.

Mrs.

Ms.

Dr.

Last Name

First Name

Date of Birth

Occupation

Type "N/A" If Not Applicable.

If other, please specify

Preferred Pharmacy

Cross Streets:

Do you have a separate card for prescription benefits?

Yes No

If Yes, Please give the benefits card to the patient service representative when you check-in

Reason(s) for today’s visit

Primary Care Provider First and Last Name

Type "N/A" If Not Applicable.

Referring Providers First and Last Name

Type "N/A" If Not Applicable.

Please write in an answer or circle yes or no to all the questions below.

Past Medical History

Have you been previously diagnosed with any of the following? (Check all that apply or None )

NONE

Add new row

List any other diseases or conditions:

List any surgical procedures you have had in the last 24 months:

Do you have and Advance Care Plan?

Yes No

If YES, please list the person's name and contact number below.

Add Additional Names

Skin Disease History:

(Check all that apply or check none.)

NONE

Add new row

If Other, please specify

Appointment Date:

Last Name:

First Name:

Date of Birth:

Do you wear sunscreen?

Yes No

If so, what SPF?

Are you currently using a tanning bed?

Yes No

Family Medical History

Do you have a family history of MELANOMA?

Yes No

If other, please specify

Medications

List all medications you are currently taking. Include prescriptions over the counter medications, vitamins, and herbals. Use additional paper if needed. Please notify our office if you decline to have your medication list imported from participating pharmacies.

PLEASE GIVE YOUR PHARMACY INSURANCE CARD TO THE FRONT OFFICE AT CHECK IN TO HELP FACILITATE YOUR MEDICATIONS ARE AUTHORIZED PROPERLY.

None

Add Additional Medications

Allergies

Are you allergic to any medications?

Yes No

If yes, list all medications

Social History

Are you a current smoker?

Yes No

Total Years Smoking

Are you a former smoker?

Yes No

Total Years Smoked

Cigarette Smoker Cigar Smoker Both

If yes, how many packs did you smoke per day?

Do you develop Keloid (raised) scars after surgery?

Yes No Not sure

Do you bleed easily?

Yes No Not sure

Have you had previous problems with any of the following? (Check all that apply or check none.)

Add new row

If Other, Please specify

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

PATIENT'S PRINTED NAME

PRINTED NAME OF GUARDIAN/RESPONSIBILITY PARTY IF DIFFERENT THAN ABOVE

SIGNATURE OF PATIENT/GUARDIAN/RESPONSIBLE PARTY

DATE

Your information will be encrypted.