Today's Date: (required)
Your name: (required)
Birth Date: (required)
Referred by: (Please list City and Phone number)
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
Other
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) AcneAsthmaDry SkinEczemaPoison IvyPsoriasisActinic KeratosesBlistering SunburnsFlaking or Itchy ScalpPrecancerous Moles (dysplastic)MelanomaBasal Cell Skin CancerHay Fever/AllergiesSquamous Cell Skin Cancer
Do you wear Sunscreen? YesNo
If yes, what SPF?
Do you tan in a tanning salon or with a lamp at home? YesNo
Do you have a family history of Melanoma? YesNo
If yes, which relative(s)?
Medications: (Please enter ALL current medications)
Allergies: (Please enter ALL known allergies)
Social History: (please choose all that apply)
Cigarette Smoking: Currently smokes every dayCurrently smokes some daysFormer SmokerNever Smoked
Alcohol Use: NoneLess than one drink per day1 - 2 drinks per day3 or more drinks per day
Occupation or Type of Workplace:
Residence: Private HomeApartmentDormitoryNursing Home
Preferred Language: (English or other)
Race:
Ethnic Group:
Preferred pharmacy: (Include Phone, City and Zip code)
Please ALERT us to any of the following that may apply to you: (please choose all that apply) Any allergy to AdhesiveAny allergy to Topical AntibioticsI have an Artificial Joint ReplacementDo you have a DefibrillatorDo you have a PacemakerRequire antibiotics prior to surgical procedureAny allergy to LidocaineDo you have an Artificial Heart ValveAre you taking any Blood ThinnersHave you ever had MRSARapid Heart Beat with Epinephrine
Pregnancy
Are you pregnant or currently trying to be pregnant? ---YesNo
Are you currently breast feeding? ---YesNo
Review of Systems:
Are you currently experiencing any of the following? (please choose all that apply) Problems with bleedingProblems with scarring (hypertrophic or keloid)Immunosuppression (depressed immune system)Night sweatsThyroid problemsBlurry visionBloody stoolJoint achesNeck stiffnessSeizuresShortness of breathAnxietyProblems with healingRashesHay feverChest painFever or chillsUnintentional weight lossSore throatAbdominal painBloody UrineMuscle weaknessHeadachesCoughWheezingDepression
Communication Consent
In addition to my consent for treatment, I, and/or for, (Patient's Name)
Give Permission ---YesNo
Or
Do NOT Give Permission ---YesNo
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.
Signature (required)
Date (required)
Patient's name if signing for minor or dependent:
