MEDICAL HISTORY FORM

Fort Bend Skin Cancer Center

281.980.6647

Patient Information

First Name

Last Name

Email address

Date of Birth

Today's Date

PRIMARY CARE PHYSICIAN OR PROVIDER

LIST OF OTHER MEDICAL SPECIALISTS

Additional Specialists

DO YOU HAVE ANY FOOD OR DRUG ALLERGIES?

Yes

If yes, please list allergens below

Additional Drugs or Other Allergens

Your Height

Your Weight

MEDICAL HISTORY

DO YOU HAVE ANY CURRENT MEDICAL PROBLEMS?

Yes No

Please list any other medical conditions not listed or checked above:

SURGICAL HISTORY

HAVE YOU HAD ANY PREVIOUS SURGERIES?

Yes No

Please list any surgeries not listed above:

SKIN CANCER HISTORY

Do you have a history of skin Cancer?

Yes No

If Yes, please list below

Add another skin cancer

FAMILY HISTORY

Do you have a family history of Melanoma?

Yes No

If Yes, which relative(s)?

Do you have a family history of Basal Cell Carcinoma?

Yes No

If Yes, which relative(s)?

Do you have a family history of Squamous Cell Carcinoma?

Yes No

If Yes, which relative(s)?

SOCIAL HISTORY

Occupation:

If Retired, Previous Occupation

Smoking History:

Never smoked

Previous smoker

Smoke every day

Smoke a few times per week

Do you drink alcohol?

Yes No

If Yes, do you drink beer?

Yes No

If Yes, number per week

If Yes, do you drink wine?

Yes No

If Yes, number per week

If Yes, do you drink distilled spirits?

Yes No

If Yes, number per week

REVIEW OF SYSTEMS

Cardiovascular

Pacemaker

Defibrillator

Artificial Heart Valve

Abnormal Heart Valve

Rapid heart rate with epinephrine

Chest Pain (Angina)

Blood Thinners

Do you take blood thinning medication?

Yes No

If so, which one(s):

Plavix

Aspirin

Eliquis

Pradaxa

Warfarin

Brilinta

Xarelto

Effient

Other

If other, which one(s)?

Allergy / Immunology

Allergy to lidocaine

Allergy to adhesives / bandages

Allergy to antibiotic ointments

Immunosuppression

Skin Disease History Have you had any of the following skin conditions?

Actinic keratoses (precancers)

Blistering sunburns

Atypical moles

Psoriasis

Fever Blisters

Rosacea

Other Skin Disease not listed above:

Do you wear sunscreen?

Yes No

If Yes, what SPF?

Do you currently tan in a tanning salon?

Yes No

Have you tanned in a tanning salon in the past?

Yes No

Other Health Information You Feel We Should Be Made Aware Of:

CURRENT MEDICATION LIST

Do you take any prescription or over-the-counter medications?

Yes No

If Yes, please list below or give the Nurse a list when you come for your visit.

Add another medication

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Keith E. Schulze, M.D.

Dr. Keith Schulze, a fellowship trained member of the American College of Mohs Surgery, opened the Fort Bend Skin Cancer Center in February 2007 after practicing in the Texas Medical Center for six years. His practice is dedicated to the treatment of skin cancer, reconstructive surgery after skin cancer removal, and the surgical treatment of benign skin lesions. Mohs micrographic surgery is a highly specialized treatment for skin cancer that offers the highest potential for cure while minimizing the cosmetic impact; even if previous treatments have failed. With advanced fellowship training as a Mohs surgeon, Dr. Schulze can provide both the thorough diagnosis and effective treatment you need to address your condition.