Established Patient Packet

Patient's Name:

DOB:

Other:

Do you have a family history of Melanoma?

Yes No

Other:

Any other family history?

Do you wear sunscreen?

Yes No

If yes, what SPF?

Do you tan in a tanning salon?

Yes No

Medications: Please list (or show us your own printed record) all prescriptions and nonprescription medications, vitamins, etc.

Preferred Pharmacy:

Phone #:

Pharmacy Location:

Allergies or Intolerance to medications (include type of reaction):

NONE

Social History:

Alcohol Use:

Do you drink alcohol?

No Yes

If Yes, #of drinks / week:

Sexual Activity:

Sexually active?

No Yes

Tobacco Use:

Smoke cigarettes?

Never No Yes

Current smoker: Packs / day:

#of years:

Quit date:

How many years did you smoke?

Drug Use:

Never No Yes

Preferred language:

Gender:

Male Female

Race:

Black Caucasian Asian American Indian/Alaskan Native Native Hawaiian/Pacific Islander

Other:

Ethnicity:

Non-Hispanic or Non-Latino Hispanic or Latino

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