History and Intake Form

Name:

Date of Birth:

Other, please specify

Other, please specify:

If Joint Replacement: Please specify:

If Organ Transplant: Please specify:

Other, please specify:

Do you wear Sunscreen?

Yes No

If yes, what SPF?

Do you tan in a tanning salon?

Yes No

Do you have a family history of Melanoma?

Yes No

If yes, which relative(s)?

Medications:

Allergies to Medications

Social History:

Currently smokes everyday Currently smokes – not daily Former smoker Never smoker

Review of Systems

Are you currently experiencing any of the following?

(please check yes or no for the following)

Symptom

Skin Problems

Yes No

Significant Stress

Yes No

Depression

Yes No

Joint Aches

Yes No

Thyroid problems

Yes No

Irregular Menses

Yes No

Headaches

Yes No

Pacemaker

Yes No

Defibrillator

Yes No

Artificial Joints w/in last 2yrs

Yes No

Artificial Heart Valve

Yes No

Premedication prior to procedures

Yes No

Allergy to adhesive

Yes No

Allergy to topical antibiotic ointments

Yes No

Allergy to latex

Yes No

Blood Thinners

Yes No

Pregnancy or planning a pregnancy

Yes No

Allergy to Lidocaine

Yes No

Rapid Heart Beat with epinephrine

Yes No

Yeast infections with antibiotics

Yes No

GI upset with antibiotics

Yes No

Problems with bleeding

Yes No

Problems with healing

Yes No

Problems with scarring (hypertrophic or keloid)

Yes No

Immunosuppression

Yes No

Other Symptoms: Please specify

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