History and Intake Form
Past Medical History: (please circle all that apply)
Anxiety
Coronary Artery
Hyperthyroidism
Arthritis
Disease
Hypothyroidism
Artificial joints
Depression
Leukemia
Asthma
Diabetes
Lung Cancer
Atrial fibrillation
End Stage Renal
Lymphoma
BPH
Disease
Pacemaker
Bone Marrow
GERD
Prostate Cancer
Transplantation
Hearing Loss
Radiation Treatment
Breast Cancer
Hepatitis
Seizures
Colon Cancer
Hypertension
Stroke
COPD
HIV/AIDS
Valve Replacement
Hypercholesterolemia
None
Other _________________________________________________________________________________________
Past Surgical History: (please circle all that apply)
Appendix Removed
Kidney Biopsy
Bladder Removed
Kidney Removed (Right, Left)
Mastectomy (Right, Left, Bilateral)
Kidney Stone Removal
Lumpectomy (Right, Left, Bilateral)
Kidney Transplant
Breast Biopsy (Right, Left, Bilateral)
Ovaries Removed: Endometriosis
Breast Reduction
Ovaries Removed: Cyst
Breast Implants
Ovaries Removed: Ovarian Cancer
Colectomy: Colon Cancer Resection
Prostate Removed: Prostate Cancer
Colectomy: Diverticulitis
Prostate Biopsy
Colectomy: IBD
TURP
Gallbladder Removed
Skin Biopsy
Coronary Artery Bypass
Basal Cell Cancer Surgery
PTCA
Squamous Cell Carcinoma Surgery
Mechanical Valve Replacement
Melanoma Surgery
Biological Valve Replacement
Spleen Removed
Heart Transplant
Testicles Removed (Right, Left,
Joint Replacement, Knee (Right, Left,
Bilateral)
Bilateral)
Hysterectomy: Fibroids
Joint Replacement, Hip (Right, Left,
Hysterectomy: Uterine Cancer
Bilateral)
None
Joint Replacement within last 2 years
Other _________________________________________________________________________________________
Skin Disease History: (please circle all that apply)
Acne
Eczema
Psoriasis
Actinic Keratoses
Flaking or Itchy Scalp
Squamous Cell Skin
Asthma
Hay Fever/Allergies
Cancer
Basal Cell Skin Cancer
Melanoma
None
Blistering Sunburns
Poison Ivy
Dry Skin
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)? ___________________________________________________________________
Medications: (Please enter all current medications)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies: (Please enter all allergies)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Social History: (Please circle all that apply)
Currently Smokes - daily
Has never smoked
Currently Smokes - not daily
Drug Use
Has smoked in the past
None
Other_________________________________________________________________________________________
Review of Systems: Are you currently experiencing any of the following?
(please check yes or no for the following)
Symptom
PaceMaker
Defibrillator
Artificial Joints
Artificial Heart Valve
Premedication before
Procedures
Allergy to adhesive
Allergy to topical
antibiotics
Blood thinners
Pregnancy or planning
pregnancy
Allergy to lidocaine
Repid heart beat with
epinephrine
Yeast infection with
antibiotics
Gi upset with antibiotics
Problems with bleeding
Problems with healing
Problems with scarring
Immunosuppression
Changing mole
Rash
Abdominal pain
Anxiety
Bloody stool
Bloody urine
Chest pain
Cough
Depression
Fever or chills
Headaches
Hay fever
Joint aches
Muscle weakness
Neck stiffness
Yes
No
Night sweats
Seizures
Shortness of breath
Sore throat
Thyroid problems
Unintentional weight loss
Wheezing
Other Symptoms: ___________________________________________________________________________