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Patient Intake Form.docx positive: Hepatitis C positive: Problems with anesthesia: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

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Page 1: Patient Intake Form.docx positive: Hepatitis C positive: Problems with anesthesia: Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

PLEASECOMPLETEANDBRINGWITHYOUTOAPPOINTMENT

www.onsitederm.com

TollFree:877-345-5300Fax:561-989-3665

Date: ______/______/_______Reason for today's visit:__________________________

Patient name: ____________________________ Phone #_______________________

Community Name: ________________________ Date of Birth:______/______/_____

Primary Insurance: ________________________ ID # __________________________

Secondary Insurance: ________________________ ID # _______________________

Are you allergic to any medications? YES NO If yes, list below:

1.________________________________2.___________________________________

List all medications you are currently taking

_____________________________________________________________________________________

Please circle to answer choice

Past Medical History – Do you have any history of:

Hypertension:

Heart Disease:

Diabetes:

Asthma/COPD:

Arthritis:

Pacemaker:

Artificial valves:

Cancer:

Keloid scarring:

Problems with healing:

Eczema:

Psoriasis:

Atypical moles:

HIV positive:

Hepatitis C positive:

Problems with anesthesia:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

PLEASECOMPLETEANDBRINGWITHYOUTOAPPOINTMENT

www.onsitederm.com

TollFree:877-345-5300Fax:561-989-3665

Patient name: ____________________________________________

Social History

Alcohol Consumption: Never Occasionally Frequently (every day)

Smoking Status: Current Everyday Some Days Former Smoker Never

Sunscreen use: Yes No At least 1 blistering sunburn: Yes No

Did you get your flu shot this year? Yes No

Did you get you pneumonia shot this year? Yes No

Any other information you would like us to know:

_____________________________________________________________________________________

Surgical History

Artificial hip joint:

Artificial joint:

Family History Family hx of skin cancer: Family hx of melanoma: Family hx of other skin diseases:

Skin Cancer History Pre skin cancer: Basal Cell Carcinoma: Squamous Cell Carcinoma: Malignant Melanoma:

Yes No Yes No

Yes No Yes No Yes No Yes No

Yes No Yes No Yes No

you take, or have you taken, Phen-Fen or Redux? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Yes Yes Yes Yes Yes Yes Yes Yes No No NO NO NO No No

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