Patient Information Form

Alabama Dermatology Associates

Date:

First Name:

Middle Name:

Last Name:

Birthdate:

Mailing Address:

City:

State:

Zip:

SS#:

Email:

Place of Employment:

Telephone #'s (including area code):

Home:

Cell:

Other:

Which should we call first?

Home Cell Other

May we leave a voicemail or text message?

Yes No

Home Address (If Student):

City:

State:

Zip:

Person Responsible for Bill:

Relation to Patient:

Mailing Address of Person Responsible:

Place of Employment of Person Responsible:

Primary Care Physician:

Referring Physician:

Gender:

Male Female

Marital Status

Single Married Divorced Widowed/Widower

Ancestry:

African Asian White Other

If Other, Please specify:

Are you Hispanic or Latino?

Yes No

Preferred Language:

English Spanish Other

If Other, Please specify:

Pharmacy Name:

Pharmacy Street:

Pharmacy City:

MEDICAL HISTORY

Add another medical problem/condition:

Add another previous surgery

Add another skin disease:

Do you wear sunscreen?

Yes No SPF

If SPF, please specify:

Do you tan in a tanning bed?

Yes No

Do you have a family history of melanoma?

Yes No

If yes, which relative?

Current Medications (including vitamins, supplements, herbals, over-the-counter, aspirin, and those for skin conditions)

Add another medication

Do you have any medication allergies?

Yes No

If yes, please list:

Add another medication allergy

Alcohol?

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

Tobacco:

Currently every day smoker Current some day smoker Former smoker Never smoker

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