New Patient Forms

SOUTHVIEW DERMATOLOGY

JANET J CASH, MD

TIMOTHY A MCGRAW, MD, FAAD

NAME

BIRTHDATE

ADDRESS

PHONE: HOME

WORK:

CELL:

MALE FEMALE

HEIGHT

WEIGHT

ETHNICITY

PHARMACY

PHONE#

FAX#

MAIL ORDER PHARMACY

ADD NEW LIST

Do you have a history of any specific skin disease?

YES NO

If yes, please list

Are you currently receiving any treatment for any specific skin disease?

YES NO

please list any treatment including the name of the physician treating you and any medications you are currently using for the skin disease (Prescription, over the counter, or herbal).

Do you bleed easily?

YES NO

Do you have AIDS or have you ever been exposed to HIV/AIDS?

YES NO

Are you pregnant or breastfeeding? (women only)

YES NO

PREVIOUS SURGERIES/INJURIES (and date)

DRUG ALLERGIES

FOOD/ENVIRONMENT ALLERGIES (if yes, list any known food or environmental factors that produce rashes).

Add new row

DO YOU HAVE A FAMILY HISTORY OF ANY OF THE FOLLOWING?

Asthma

YES NO

Relationship

Eczema/Atopic Dermatitis

YES NO

Relationship

Excessive Hair Growth

YES NO

Relationship

Hay Fever

YES NO

Relationship

Hereditary Hair Loss

YES NO

Relationship

Melanoma

YES NO

Relationship

Non-melanoma skin cancer

YES NO

Relationship

Psoriasis

YES NO

Relationship

Severe Acne

YES NO

Relationship

Other Hereditary Skin Disease

YES NO

Relationship

If yes, please list

SOCIAL HISTORY

Single Married Divorced Widowed

CHECK ALL THAT APPLY

Cigarettes packs per day

Past history of excessive sun exposure/burning

Tan Only Tan and burn Burn

Outdoor Occupation

tan in sun-recreational

Tanning bed use

Former occasional Former regular Current occasional Current regular

Occupation

Hobbies

Forms completed by:

Patient Parent/Guardian Medical Assistant Nurse Other

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date

Patient/Guardian Signature

Date

Physician Signature

Date

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