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Patient Registration and Health Questionnaire
Last Name
*
M.I.
*
First Name
*
Date of Birth
*
Age
*
Sex
M
F
Social Security #
Address
*
City
*
State
*
Zip Code
*
Home Phone #
Mobile #
Work Phone #
Preferred Number
Home
Mobile
Work
May we leave a detailed message?
Yes
No
May we text appointment reminders?
Yes
No
Email
May we email appointment reminders?
Yes
No
Would you like to be notified of promotions and events?
Yes
No
Emergency Contact
Name
Phone #
CONSENT TO DISCUSS CARE. If you are 18 years or older we cannot discuss your care with other family members, spouses or caretakers without your consent. Do you authorize consent for any other individuals?
Yes
No
If yes:
Name
Relationship
Phone #
Employer
Occupation
Primary Care Physician (Name and Location)
How did you hear about us?
Preferred pharmacy (Name and Location)
Past Medical History
None
Anxiety disorder
Arthritis
Asthma
Atrial fibrillation
Benign prostatic hyperplasia
Cerebrovascular accident
Chronic obstructive lung disease
Coronary arteriosclerosis
Depressive disorder
Diabetes mellitus
Disease caused by 2019-nCoV
Elevated blood pressure
End Stage renal disease
Epilepsy
Gastrooesophageal reflux disease
H/O: hypertension
Hearing loss
Human immunodeficiency virus infection
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Inflammatory disease of liver
Leukemia
Malignant lymphoma
Malignant tumor of lung
Malignant tumour of breast
Malignant tumour of colon
Malignant tumour of prostate
Radiation therapy treatment management
Transplantation of bone marrow
Other:
Other:
Past Surgical History (including dates)
Skin Disease History
Acne
Actinic Keratoses
Asthma
Blistering Sunburns
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Poison Ivy
Precancerous Moles
Psoriasis
Other:
Other:
History of Skin Cancer
Location
Year
Basal Cell:
Location
Year
Melanoma:
Location
Year
Squamous cell:
Location
Year
Unknown:
Location
Year
Other:
Location
Year
Do you wear Sunscreen?
*
Yes
No
If yes, what SPF?
If yes, what SPF?
Do you tan in a tanning salon?
*
Yes
No
Do you have a family history of melanoma?
*
Yes
No
If yes, who?
If yes, who?
Medications (Prescription, over-the-counter, and herbal)
Allergies
Cigarette Smoking
*
Never smoked
Quit: former smoker
Current every day smoker
Current some day smoker
Do you have any of the following?
Chest pain
Shortness of breath
Fever or chills
Unintentional weight loss
Night sweats
Joint aches
Headaches
Alerts
Pacemaker
Defibrillator
Artificial joints within past two years
Artificial heart valve
Premedication prior to procedures
Blood thinners
Pregnancy or planning a pregnancy
Breastfeeding
Bleeding disorder
Allergy to adhesive
Latex allergy
Allergy to topical antibiotic ointments
Allergy to lidocaine
Rapid heart beat with epinephrine
Problems with scarring (hypertophic or keloid)
HIV Positive
Hepatitis positive (Hep A, B or C)
All information entered into this form is transmitted through a secure network directly to our office and becomes protected health information.