Patient Medical History Form

Patient Name:

Date of Birth:

Pharmacy Name:

Street:

Zip Code:

Telephone:

Past Dermatologic/Skin History

Have you ever had skin cancer?

Yes No

If YES, which kind: (select all that apply)

Basal Cell Carcinoma

Squamous Cell Carcinoma

Melanoma

Do you have a family history of MELANOMA?

Yes No

If yes, which relative(s):

Do you have a family history of any other cancers such as breast, ovarian, pancreatic, prostate, lung, etc. in your family?

Yes No

If yes, which relative(s), mother’s or father’s side and type of cancer:

Other information we should know about your skin:

Social History

Do you smoke?

Yes No

If YES, how many packs a day?

How much alcohol do you consume?

Past Major Medical History:

Ongoing Medical/Health Issues:

Alerts

Currently taking Blood thinners

Yes No

Pacemaker

Yes No

Artificial Joints

Yes No

Pre-medication prior to procedures

Yes No

Allergies

Have you ever had an allergic reaction to any drug or medication?

Yes No

If YES, please list the drug(s) and type of reaction(s):

Drug:

Reaction

Add drug and reaction info

Are you allergic to latex?

Yes No

Are you allergic to lidocaine / local anesthesia?

Yes No

Are you allergic to adhesive?

Yes No

Medications

NO current medications

Medication Name:

Dosage:

Reason:

Add medication

By signing below, I acknowledge the information is true and correct to the best of my knowledge.

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Patient Signature:

Date:

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