Oahu Dermatology LLC-Intake and History Form

Dr. Carla Nip-Sakamoto, M.D., Dr. Miki Garcia, M.D., Dr. Summer Chong, M.D.

Name

Date of Birth

Referring Physician (if any)

PCP

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

Skin conditions:

None

Acne

Actinic keratosis

Dysplastic naevus of skin

Eczema

Psoriasis

Sunburn of second degree

Other:

If other, specify:

Do you have a family history of Melanoma?

Yes No

Do you wear sunscreen?

Yes No

If yes, what SPF?

Medications (list all current medications):

Allergies

No known drug allergies

Yes No

If yes, Please specify your allergy and reaction

Allergy to adhesive

Yes No

If yes, Please specify your allergy and reaction

Allergy to lidocaine

Yes No

If yes, Please specify your allergy and reaction

Allergy to topical antibiotic ointments

Yes No

If yes, Please specify your allergy and reaction

Allergy to latex

Yes No

If yes, Please specify your allergy and reaction

Please specify if you have allergies to any other medications as well the reaction

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, Please 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 or keloid)

Yes No

Rash

Yes No

Immunosuppression

Yes No

Fever or Chills

Yes No

Fatigue

Yes No

Unintentional weight loss

Yes No

Sore throat

Yes No

New loss of taste or smell

Yes No

Blurry Vision

Yes No

Abdominal pain

Yes No

Joint aches

Yes No

Muscle Weakness

Yes No

Headaches

Yes No

Cough

Yes No

Anxiety

Yes No

Depression

Yes No

Alerts

Artificial heart valve placement

Yes No

MRSA

Yes No

Blood thinners

Yes No

Artificial joints within past two years

Yes No

Pacemaker

Yes No

Premedication prior to procedures

Yes No

Defibrillator

Yes No

Pregnancy or planning a pregnancy

Yes No

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