Advanced Dermatology History and Intake Form 2015
Name__________________________________________________________Date_____________________
Past Medical History: (please check all that apply)
Anxiety
Arthritis
Asthma
Atrial fibrillation (Irreg. heartbeat)
Bone Marrow Transplantation
BPH
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Kidney (Renal) Disease
GERD-Gastro Esophageal Reflux Disorder
Hearing Loss
Hepatitis
High Blood pressure-Hypertension
HIV/AIDS
High Cholesterol (Hypercholesterolemia)
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
NONE of the above
Other (list all):
Past Surgical History: (please check and circle all that apply)
Appendix Removed (Appendectomy)
Bladder Removed (Cystectomy)
Mastectomy (Right, Left, Bilateral-Both)
Lumpectomy (Right, Left, Bilateral-Both)
Breast Biopsy (Right, Left, Bilateral-Both)
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD (Inflammatory Bowel Disease)
Colon: Colostomy
Gallbladder Removed (Cholecystectomy)
Heart: Coronary Artery Bypass Surgery
Heart: PCTA (Percutaneous Transluminal Coronary
Liver: Liver Transplant
Liver: Liver Removal (Hepatectomy)
Ovaries Removed: Endometriosis (Oophorectomy)
Ovaries Removed: Ovarian Cysts (Oophorectomy)
Ovaries Removed: Ovarian Cancer (Oophorectomy)
Ovaries: Tubal Ligation
Pancreas: Removal (Pancreatectomy)
Prostate Cancer: Prostate Removed (Prostatectomy)
Prostate Cancer: Prostate Biopsy (Prostatectomy)
TURP :Transurethral Resection of the Prostate
Rectum: Anterior, Posterior Repair (APR)
Rectum: Low Anterior Resection
Angioplasty)
Heart: Mechanical Valve Replacement
Heart: Transplant
Joint Replacement, Knee (Right, Left, Bilateral-Both)
Joint Replacement, Hip (Right, Left, Bilateral-Both)
Joint Replacement within last 2 years
Kidney Biopsy
Kidney Removed –Nephrectomy (Right, Left)
Skin: Biopsy
Skin: Basal Cell Carcinoma
Skin: Squamous Cell Carcinoma
Skin: Melanoma
Spleen Removed (Splenectomy)
Testicles Removed – Orchiectomy (Right, Left, Bilateral)
Uterus - Hysterectomy: Fibroids
Kidney Stone Removal
Kidney Transplant
Liver: Shunt
Uterus - Hysterectomy: Uterine Cancer
Uterus - Hysterectomy: Cervical Cancer
NONE of the above.
Other (list all):
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Advanced Dermatology History and Intake Form 2015
Name___________________________________________________Date____________________________
SKIN DISEASE HISTORY: (please check all that apply)
Acne
Dry Skin
Actinic Keratosis
Eczema
Asthma
Flaking or Itchy Scalp
Basal Cell Skin Cancer
Hay Fever/Allergies
Blistering Sunburns
Melanoma
Other (list):
SKIN PROTECTION HISTORY
Do you wear Sunscreen?
Poison Ivy
Precancerous Moles (Atypical, Clarks, Dysplastic)
Psoriasis
Squamous Cell Skin Cancer
NONE
FAMILY HISTORY: (does your family YES
have history of?)
Basal Cell Carcinoma
Squamous Cell Carcinoma
Eczema
Melanoma
If yes to Melanoma, which relative(s)?
YES NO
If yes, what SPF?
Do you tan in a tanning salon?
MEDICATIONS: (please list all current medications,
NO
ALLERGIES: (please list all allergies)
use reverse side of last form if necessary)
Medication
Strength
Form
Route
Freq.
Indication
Medication
Reaction Type
SOCIAL HISTORY: (Please check all that apply)
Smoking:
Currently smokes
Former smoker
Never smoked
ALERTS: (please check yes or no)
Have you ever had difficulty stopping bleeding?
Alcohol Use:
None
less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Yes
No
Do you require antibiotics prior to a surgical procedure?
Have you had an artificial joint replacement?
If yes, list when and what body locations?
Do you have an artificial heart valve?
Do you have a pacemaker?
Do you have a defibrillator?
Are you pregnant or currently trying to get pregnant?
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Advanced Dermatology History and Intake Form 2015
Name___________________________________________________Date____________________________
REVIEW OF SYSTEMS:
ALERTS (continued):
Are you currently experiencing any of the following?
Have you ever experienced or used any of the following?
SYMPTOM
Problems with Bleeding
Problems with Healing
Problems with scarring
(hypertrophic or keloid)
Rash
Fever/Chills
Night Sweats
Unintentional weight loss
Blurry vision
Sore Throat
Difficulty swallowing
Oral sores
Cough
Shortness of Breath
Wheezing
Palpitations
Chest pain
Valvular heart disease
History of Heart Attack/Stroke
Abdominal pain
Bloody Stool
Diarrhea
Constipation
Bloody Urine
Burning on urination
Joint aches
Muscle Weakness
Neck Stiffness
Headaches
Seizures
Numbness/tingling
Depression
Photosensitivity
Raynauds
SYMPTOM
Accutane Use
Immunosuppressive/Biologics Use
Immunosuppressive/ Organ
Transplant
Immunosuppressive/Other
Allergy to adhesive
Allergy to lidocaine
Allergy to topical antibiotic ointments
Artificial heart valve
Artificial joints within past two years
Blood thinners
Defibrillator
MRSA
Pacemaker
Premedication prior to procedures
Rapid heartbeat with epinephrine
Latex allergy
Other:
YES
NO
YES
NO
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