HAGERSTOWN DERM & SKIN CARE
REGISTRATION FORM
(Please Print)
Today’s date:
PCP:
PATIENT INFORMATION
Patient’s Last name:
First:
Sex:
M
Middle:
Ethnicity: Hispanic or Latino?
Non-Hispanic or Non-Latino?
F
 Mr.
 Mrs.
Race:
Street address:
Marital status (circle one)
 Miss
 Ms.
Single / Mar / Div / Sep / Wid
Birthdate :MM/DD/YY
Social Security no.:
Home phone no.:
(
Cell Phone no.:
(
City:
Age:
)
State:
ZIP Code:
)
Occupation:
Employer:
Employer phone no.:
(
Chose our office because/ or
Referred to us by (please check one box):
 Family
 Friend
 Dr
 Internet/Google
)
 Hospital
 Insurance
Plan
 Close to home/work
Other family members seen here:
EMAIL Address:
INSURANCE INFORMATION
(Please give your insurance card and ID to the receptionist.)
Person responsible for bill:
Birthdate:
/
 Yes
Occupation:
Employer:
Address (if different):
Home phone no.:
/
(
)
 No
Employer address:
Employer phone no.:
(
)
Please indicate Name and claim
address of primary insurance:
Subscriber’s name:
Subscriber’s S.S. no.:
Birthdate:
/
Patient’s relationship to subscriber:
 Self
Name of secondary insurance (if applicable):
Patient’s relationship to subscriber:
 Self
 Spouse
Group no.:
/
 Child
$
 Other
Subscriber’s name:
 Spouse
Specialist
Co-payment:
Policy no.:
Group no.:
 Child
Policy no.:
 Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):
Relationship to patient:
Home phone no.:
Work phone no.:
(
(
)
)
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Johanna Fangmeyer, CRNP
(Provider.) I understand that I am financially responsible for any balance. I also authorize Hagerstown Derm & Skin Care or insurance company to
release any information required to process my claims.
Patient/Guardian signature
Date
MEDICAL HISTORY
Patient name: ___________________________________________________________________
Reason for today’s visit? ___________________________________________________________
- How long has this been a problem? _________________________________
- Have you tried any treatments or medications in the past for your current condition? YES NO
If yes, please list medications and over the counter items you have tried:
___________________________________________________________________________
Pharmacy Name/Address: _________________________________________________________
Current Medications If N/A - Circle NONE
Include prescriptions, over-the-counter meds (such as aspirin), vitamins, supplements and herbal products:
_____________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________
Allergies
If N/A- Circle NONE
List all medications, seasonal/environmental, foods, adhesive, latex – and include reactions:
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________
Female patients: Pregnant? ______
Planning a pregnancy? ______ Currently Breastfeeding? ______
Birth control? If yes, please list name of pill, or contraception method you are using currently:
_____________________________________________
Past Medical History: (Please circle all that apply)
Arthritis/Joint problems
GERD/Esophageal Reflux
Pacemaker
Anxiety
Hearing Loss
Radiation Treatment
Asthma
HIV infection/ AIDS
Seizures
Atrial Fibrillation (Irregular Heartbeat)
Hepatitis
Stroke
Blood clots or clotting disorder
Hypercholesterolemia
Varicose Veins
Bronchitis
Hypertension/blood pressure problems
Cancer (what type) ___________________ Hyperthyroidism
COPD
Hypothyroidism
Coronary Artery Disease
Leukemia
Depression
Lymphoma
Diabetes
Lupus
Fainting
Night Sweats
Other:________________________________________________________________________________
Past Surgical History: (Please circle all that apply)
Appendix Removed
Heart: Mechanical Valve Replacement
Bladder
Heart: Biological Valve Replacement
Breast: Mastectomy R L Both Joint Replacement: Knee R L Both
Breast: Lumpectomy R L Both Joint Replacement: Hip R L Both
Breast Biopsy
Kidney Biopsy
Breast Reduction
Kidney Removed R L Both
Breast Implants
Kidney Stone Removal
Colectomy: Colon Cancer Resection
Ovaries Removed: Cyst
Colectomy: Diverticulitis
Tubal Ligation
Skin Biopsy
Skin Cancer:
Basal Cell
Squamous Cell
Melanoma
Spleen Removal
Hysterectomy:
Fibroids
Uterine Cancer
Colectomy: Inflamm. Bowel Disease
Gallbladder
Heart: Coronary Artery Bypass
Endometriosis
Ovarian Cancer
Prostate Removed: Cancer
Testicle Removal
Tonsillectomy
Other: _____________________
Personal Skin History: (Please circle all that apply)
Acne
Actinic Keratosis (Pre-cancers)
Asthma
Basal Cell Skin Cancer
Dry Skin
Eczema
Flaking or Itchy Scalp
Psoriasis
Hay Fever/Allergies
Warts
Melanoma
Cold Sores
Poison Ivy/Rashes
Blistering Sunburns
Atypical/“Pre-Cancerous” Moles
Significant sunburns
Squamous Cell Skin Cancer
Infection/MRSA
Tanning bed use? Current _____
Past ______
For how long/how often? ____________________________________________________
Sunscreen use (circle):
Daily
Occasionally
Only at the Beach
I don’t use sunscreen
Social History:
Smoking:
Alcohol:
Current every day smoker _____
Current some day smoker (tobacco)____
Current some day smoker (cigarette)____
None ______
1-2 drinks/day_____
Never Smoker_____
Former Smoker_____
less than 1 drink/day_____
3 or more drinks/day_____
Family History (blood relative i.e., grandmother, brother, child.)
Acne _______________________
Allergies/Hayfever _____________________________
Eczema _____________________ Psoriasis _____________________________________
Auto-Immune Disorders (thyroid, Lupus, M.S., Vitiligo) ______________________________
Other: _____________________________________________________________________
Skin Cancer _______________________________ Type? (Circle)
Basal Cell Carcinoma
I
Squamous Cell Carcinoma
Melanoma
Please check here if you are interested in receiving more information about:
Chemical Peels _____
Sun Protection/Sunscreens _____
Wrinkle relaxers (Botox, Dysport) _____
Wrinkle fillers (Restylane, Juvaderm) _____
Skin Care/Anti-Aging Products _____
Treatment of Excessive Underarm Sweating _____
Spider Veins on the legs (Sclerotherapy) _____
REQUEST FOR CONFIDENTIAL COMMUNICATIONS
I request that all communications to me (via telephone, mail or otherwise) by Hagerstown
Dermatology and Skin Care and/or its staff are handled in the following manner:
For written communications: (Mailing address)
 ________________________________________________________________
For oral communications: (Telephone number)
 _______________________________________________________________________________

Email Address: ________________________________________________________________
Would you like to receive information on specials, or relevant information?  Yes  No
Do we have permission to:
Leave a message on your machine at home?  YES  NO
Leave a message at your place of employment?
 YES  NO
Discuss your Medical Condition or results with any member of your household?  YES  NO
If Yes, Whom: _______________________________________________________________
Relationship:_________________________________________________________________
_________________________________________
Patient Signature
____________________
Date