Advanced Dermatology History and Intake Form

    Past Medical History: (please choose all that apply)
    AnxietyArthritisAsthmaAtrial fibrillationBone MarrowTransplantationBreast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesKidney DiseaseGERDHearing LossHepatitisHigh Blood pressureHIV/AIDSHigh CholesterolLeukemiaLung CancerLymphomaProstrate CancerRadiation TreatmentSeizuresStrokeHypothyroidismHyperthyroidismNone

    Past Surgical History: (please choose all that apply)
    Appendix RemovedBladder RemovedMastectomy (Right, Left, Bilateral)Lumpectomy (Right, Left, Bilateral)Breast Biopsy (Right, Left, Bilateral)Breast ReductionBreast ImplantsColectomy: Colon Cancer ResectionColectomy: DiverticulitisColectomy: Irritable Bowel DiseaseGallbladder RemovedCoronary Artery BypassMechanical Valve ReplacementBiological Valve ReplacementHeart TransplantJoint Replacement, Knee (Right, Left, Bilateral)Joint Replacement, Hip (Right, Left, Bilateral)Joint Replacement within last 2 yearsKidney Biopsy (Nephrectomy)Kidney Removed (Right, Left)Kidney Stone RemovalKidney TransplantOvaries Removed: EndometriosisOvaries Removed: CystOvaries Removed: Ovarian CancerProstrate Removed: Prostrate CancerProstate BiopsyTURP (Prostate Removal)Spleen RemovedTesticles Removed (Right, Left, Bilateral)Tonsils & Adenoids removedTubal LigationHysterectomy: FibroidsHysterectomy: Uterine CancerNone

    Skin Disease History: (please choose all that apply)

    Social History: (please choose all that apply)

    Cigarette Smoking:

    Alcohol Use:

    Residence:

    Please ALERT us to any of the following that may apply to you: (please choose all that apply)

    Pregnancy

    Are you pregnant or currently trying to be pregnant?

    Are you currently breast feeding?

    Review of Systems:

    Are you currently experiencing any of the following? (please choose all that apply)

    Communication Consent

    Or

    for representatives of Advanced Dermatology, Inc. and Dr. Monique S. Cohn to communicate information regarding biopsy results and other personal medical and health information regarding diagnoses, treatments and procedures related to my visits at Advanced Dermatology by phone or emails I have provided to the practice. Also, the practice may leave voice messages at my contact numbers and or messages with immediate family members regarding my medical conditions or results.