History and Intake Form

Please correct the errors described below.

Patient Name

Date of Birth

Past Medical History Check all that apply

Anxiety

Arthritis

Asthma

Atrial fibrillation

Bone marrow transplant

Cancer

COPD

Depression

Diabetes

End-Stage Renal Disease

GERD

PCOS

Hearing loss

Hepatitis

HIV/AIDS

Hypertension

Overactive thyroid

Underactive thyroid

Leukemia

Coronary Artery Disease

Radiation treatment

Seizures

Stroke

Pacemaker/Defibrillator

Other

If bone marrow transplant, what year?

If cancer, what type?

If radiation treatment, what kind?

If hepatitis, what type (if known)?

If other, please explain

Major Surgeries Check all that apply

Right knee replacement

Left knee replacement

Colon surgery

Gallbladder removed

Heart surgery

Right hip replacement

Left hip replacement

Full Hysterectomy

Partial Hysterectomy

Right Lumpectomy

Left Lumpectomy

Bilateral Lumpectomy

Right Mastectomy

Left Mastectomy

Bilateral Mastectomy

Organ transplant

Ovaries removed

TURP

Right Testicles removed

Left Testicles removed

Bilateral Testicles removed

Other

If heart surgery, what type?

If organ transplant, which organ?

If other, please explain

Skin Disease History Check all that apply

Acne

Blistering sunburns

Dry skin

Eczema

Melanoma

Basal cell carcinoma

Squamous cell carcinoma

Poison Ivy rash

Psoriasis

Rosacea

Abnormal Moles

Actinic keratosis (pre-skin cancer)

Efudex/Fluorouricil

MOHs surgery

If melanoma, what year?

If basal cell carcinoma, what year?

If squamous cell carcinoma, what year?

Social History

Tobacco Use

Current Smoker

Daily

Not Daily

Smoked in the past

Never smoked

Alcohol Use

Social Only

< 1 drink daily

1-2 drinks daily

> 3 drinks daily

None

Family History (Mother, Father, Sister, Brother, or Children)

Melanoma

Rheumatoid arthritis

Non-melanoma skin cancer

Polycystic ovary disease

Severe acne

Alerts Check all that apply

Artificial joint

Blood thinners

HIV/Hepatitis

Pacemaker

Antibiotics prior to surgery

Artificial heart valve

Defibrillator

Immunosuppressant

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