History and Intake Form
Patient Name: __________________________
Date of Birth: ___________________
Ethnicity (optional question, please circle one): Hispanic/Latino or Non Hispanic/Latino
Race (optional question, please circle one): American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Asian
White
Black or African American
Other Race
Preferred Language: ______________________________
Preferred Pharmacy Name: ___________________ Address: _________________ Phone #:__________________
Past Medical History: (Please circle all that apply)
Anxiety
Arthritis
Artificial Joints
Asthma
Atrial Fibrillation
BPH
Bone Marrow Transplant
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Pacemaker
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Valve Replacement
None
Other: _______________________________________________________________________________________
Past Surgical History: (Please circle all that apply)
Appendix Removed
Bladder Removed
Mastectomy (R,L,Bilateral)
Lumpectomy (R,L,Bilateral)
Breast Biopsy
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
PTCA
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement, Hip (R,L,Bilateral)
Joint Replacement Knee (R,L,Bilateral)
Joint Replacement within last 2 years
Kidney Biopsy
Kidney Removed (R,L)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP
Skin Biopsy
Basal Cell Cancer Surgery
Squamous Cell Carcinoma Surgery
Melanoma Surgery
Spleen Removed
Testicles Removed (R,L,Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
None
Other: ______________________________________________________________________________________
Skin Disease History: (Please circle all that apply)
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaking/Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy
Psoriasis
Squamous Cell Skin Cancer
Precancerous Moles None
Other: _______________________________________________________________________________________
Do you wear sunscreen?
Yes/No
Do you tan at a tanning salon?
Yes/No
Do you have a family history of melanoma? Yes/No
If yes, which relatives? ______________________________
Any other family history: _____________________________________________________________________________
Medications: (Please list all current medications)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Allergies: (Please list all current allergies)
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Social History: (Please circle all that apply)
Cigarette Smoking:
Never Smoked
Quit/Former Smoker
Smokes Less Than Daily
Smokes Daily
Other: ___________________________________________________________________________________________
Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for all)
Symptom
Yes
No
Currently pregnant or planning a pregnancy
Recent fevers
Recent Unintended Weight Loss
Problems with bleeding
Excessive Scarring
Immunosuppressed
Joint Pain/Swelling
Other Symptoms: ____________________________________________________
Alerts: Are you currently experiencing any of the following? (Please check yes or no for all)
Alert
Yes
Allergy to adhesive
Pacemaker/Defibrillator
Latex Allergy
Lidocane/Numbing Medicine Allergy
Artifical heart valve
Artifical Joints within last 2 years
Other Symptoms: ____________________________________________________
No