History and Intake Form

Name

Date of Birth

Reason For Today's Visit

If Other, Please specify

If yes, what SPF?

If yes, which relative(s)?

Any other family history?

Medications (please enter all current medications and non-prescription medications)

I am currently not taking medications

Allergies (please enter all allergies and type of reaction)

I am not allergic to any medications

Social History (please check one)

Cigarette Smoking

Never smoked

Quit (former smoker)

Current Smoker

Other

If yes, Drinks/day?

If Other, Please specify

Other, Please specify

Immunizations

Flu Vaccine

Pneumonia Vaccine

Shingles Vaccine

Pharmacy Name

City

Zip

Review of Systems Currently Experiencing

None

New/Changing Skin Lesions

New Lumps Under Skin

Slow Wound Healing

Abnormal Scarring

Fever/Chills

Weight Loss

Other

If Other, Please specify

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Signature

Date

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