NAME:
DATE OF BIRTH:
History and Intake Form
Past Medical History: (please circle all that apply)
Anxiety
Hepatitis
Arthritis
Hypertension
Asthma
HIV/AIDS
Atrial fibrillation
Hypercholesterolemia
BPH (Benign Prostatic Hyperplasia)
Hyperthyroidism
Bone Marrow Transplantation
Hypothyroidism
Breast Cancer
Leukemia
Colon Cancer
Lung Cancer
COPD (Emphysema)
Lymphoma
Coronary Artery Disease
Pacemaker
Depression
Prostate Cancer
Diabetes
Radiation Treatment
End Stage Renal Disease
Seizures
GERD (Acid reflux)
Stroke
Hearing Loss
None
Past Surgical History: (please circle all that apply)
Appendix Removed
Joint Replacement, Hip (Right, Left,
Bladder Removed
Bilateral)Date_______________________
Mastectomy (Right, Left, Bilateral)
Kidney Biopsy
Lumpectomy (Right, Left, Bilateral)
Kidney Removed (Right, Left)
Breast Biopsy (Right, Left, Bilateral)
Kidney Stone Removal
Breast Reduction
Kidney Transplant
Breast Implants
Ovaries Removed: Endometriosis,
Colectomy: Colon Cancer Resection
Cyst, Cancer
Colectomy: Diverticulitis
Prostate Removed: Prostate Cancer
Colectomy: IBD
Prostate Biopsy
Gallbladder Removed
TURP
Coronary Artery Bypass
Skin Biopsy
PTCA
Basal Cell Cancer Surgery
Biological /Mechanical Valve
Squamous Cell Carcinoma Surgery
Replacement
Melanoma Surgery
Heart Transplant
Spleen Removed
Joint Replacement, Knee (Right, Left,
Testicles Removed (Right, Left,
Bilateral)Date_______________________
Bilateral)
None
Hysterectomy: Fibroids, Cancer
Skin Disease History: (please circle all that apply)
Acne
Blistering Sunburns
Actinic Keratosis
Dry Skin
Asthma
Eczema
Basal Cell Skin Cancer
Flaking or Itchy Scalp
K:/office forms/ema intake form
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NAME:
DATE OF BIRTH:
Hay Fever/Allergies
Psoriasis
Melanoma
Squamous Cell Skin Cancer
Poison Ivy
None
Precancerous Moles
Other ________________________________________________________________________________________
Do you wear Sunscreen?
Yes
If yes, what SPF? ___________
Do you tan in a tanning salon?
No
Yes
No
Do you have a family history of Melanoma?
Yes
No
If yes, which relative(s)? ___________________________________________________________________
Any other family history: __________________________________________________________________
Medications: (Please enter all current medications)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies: (Please enter all allergies)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
How long has current spot/spots been present?__________________________________________
What symptoms have you had? (circle one) Itching, bleeding, pain, growing , color
What treatment have you had other than biopsy? Excision, scraping, freezing, cream
Social History: (Please circle one)
Cigarette/Cigar Smoking:
Alcohol Use:
Never smoked
YES Social/Daily
Quit: former smoker
NO
Smokes less than daily
Smokes daily
Race:
White
Black/African American
Asian
American Indian or Native Alaskan
Language:
English
Spanish
Other:_________
Ethnicity:
Hispanic/Latino
Non-Hispanic/Latino
Native Hawaiian/Pacific
Islander
Place of residence: (circle one) Home, Nursing home, Assisted living
Occupation: _______________________________________ Retired _______________________________
Primary Care Physician_________________________ Cardiologist__________________________
Pharmacy Name ______________________________________
Street:________________________________________ __________
K:/office forms/ema intake form
Phone:
________
Zip code:_________________________
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