Family History and Intake Form

Name:

Date:

Other

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: (Please enter all current medications)

Allergies: (Please enter all allergies)

Social History: (Please circle all that apply)

Cigarette Smoking

Currently Smokes Never Smoked Former Smoker

Date Stopped

Alcohol Use

EtOH - None EtOH - less than 1 drink per day EtOH - 1-2 drinks per day EtOH - 3 or more drinks per day

Family History (Only first-degree relatives)

Are you pregnant or currently trying to get pregnant?

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Patient's Signature

Date

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