History and Intake Form
Todays Date _______________________________
Patient Name _______________________________________________________________________________________
(Last)
(First)
(Middle Initial)
Date of Birth _______________________________
(Month) (Day) (Year)
Reason for todays visit:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Past Medical History: (please circle all that apply)
Anxiety
Arthritis
Asthma
Atrial fibrillation
Bone Marrow
Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Disease
GERD
Hearing Loss
Hepatitis
If Yes, What Type? ______
Current/Past
Treatment? _____________
High Blood pressure
HIV/AIDS
High Cholesterol
Thyroid Problems
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
NONE
Other _________________________________________________________________________________________
Past Surgical History: (please circle all that apply)
Appendix Removed
Bladder Removed
Mastectomy (Right, Left, Bilateral)
Lumpectomy (Right, Left, Bilateral)
Breast Biopsy (Right, Left, Bilateral)
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: IBD
Gallbladder Removed
Coronary Artery Bypass
Patient Name _______________________________________________________________________
(Last)
(First)
(Middle Initial)
Mechanical Valve Replacement
Biological Valve Replacement
Heart Transplant
Joint Replacement
If yes, what joint(s)? _______________________
what year(s)? _______________________
Kidney Biopsy (Nephrectomy)
Kidney Removed (Right, Left)
Kidney Stone Removal
Kidney Transplant
Ovaries Removed: Endometriosis
Ovaries Removed: Cyst
Ovaries Removed: Ovarian Cancer
Prostate Removed: Prostate Cancer
Prostate Biopsy
TURP (Prostate Removal)
Spleen Removed
Testicles Removed (Right, Left, Bilateral)
Hysterectomy: Fibroids
Hysterectomy: Uterine Cancer
NONE
Other _________________________________________________________________________________________
Personal Skin Disease History: (please circle all that apply)
If Circled, Please specify
Location and Treatment
Basal Cell Skin Cancer
Squamous Cell Skin Cancer
Melanoma
Dysplastic/Abnormal
Moles
Actinic Keratoses (PreCancers)
Location(s)
Treatment(s)
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
(Blue Light Treatment
/Efudex (Fluorouracil)
Carac/Aldara/Liquid
Nitrogen)
(Excision/Mohs/Radiation)
Acne
Asthma
Blistering Sunburns
Dry Skin
Flaking or Itchy Scalp
Eczema
Hay Fever/Allergies
Psoriasis
Poison Ivy
Other ________________________________________________________________________________________
Do you wear Sunscreen?
Yes
If yes, what SPF? ___________
Do you tan in a tanning salon?
No
Yes-Current Use
Yes-Past Use
No
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Patient Name _______________________________________________________________________
(Last)
(First)
(Middle Initial)
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 and the reaction you have to each medication,
ex: Penicillin, Rash as child)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________
Social History: (Please circle all that apply)
Cigarette Smoking:
Currently Smokes
Former Smoker
If yes, What year did you quit? _________
Never smoked
Alcohol Use:
None
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Occupation ________________________________
Other Medical History
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Preferred Language: _____________________________
Race:________________________
Ethnic Group:___________________________
Preferred Pharmacy Name: _____________________________
Phone#: _______________________________
City or Zip code:____________________
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Patient Name _______________________________________________________________________
(Last)
(First)
(Middle Initial)
Review of Systems: (Please check yes or no for the following)
Symptom
Immunosuppression
Problems with Healing
Problems with Bleeding
Problems with Scarring
Rash
Hay Fever
Fever/Chills
Night Sweats
Unintentional Weight Loss
Abdominal Pain
Joint Pain
Headaches
Cough
Shortness of Breath
Depression
Anxiety
Yes
No
ALERTS: (please circle all that apply)
Allergy to Lidocaine
Rapid heart beat with epinephrine
Defibrillator
Artificial joint replacement in past 7 years
Require antibiotics prior to a surgical procedure If Yes, What Antibiotic __________________
History of MRSA
Blood thinners
Allergy to adhesive
Allergy to topical antibiotics
Artificial heart valve
Pacemaker
Are you pregnant or currently trying to get pregnant?
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