History and Intake Form (P.1)

History and Intake Form (P.1)
Patient Name
Date of Birth
Past Medical History (Please check all that apply)
Anxiety
Depression
Leukemia
Arthritis
Diabetes
Lung Cancer
Artificial Joints
End Stage Renal Disease
Lymphoma
Asthma
GERD
Pacemaker/Defibrillator
Atrial Fibrillation
Hearing Loss
Prostate Cancer
Benign Prostatic Hypertrophy (BPH)
Hepatitis
Radiation Treatment
Bone Marrow Transplantation
Hypertension
Seizures
Breast Cancer
HIV/AIDS
Stroke
Colon Cancer
Hypercholesterolemia
Valve Replacement
COPD
Hyperthyroidism
None
Coronary Artery Disease
Hypothyroidism
Other
Past Surgical History (Please check all that apply)
Appendix Removed
Mechanical Valve Replacement
Ovaries Removed, Ovarian Cancer
Bladder Removed
Biological Valve Replacement
Prostate Removed, Prostate Cancer
Mastectomy (Right, Left, Bilateral)
Heart Transplant
Prostate Biopsy
Lumpectomy (Right, Left, Bilateral)
Joint Replacement, Knee (Rt, Lft, Bi)
TURP
Breast Biopsy (Right, Left, Bilateral)
Joint Replacement, Hip (Rt, Lft, Bi)
Skin Biopsy
Breast Reduction
Joint Replacement with last 2 years
Basal Cell Cancer Surgery
Breast Implants
Kidney Biopsy
Squamous Cell Carcinoma Surgery
Colectomy - Colon Cancer Resection
Kidney Removed (Right, Left)
Melanoma Surgery
Colectomy - Diverticulitis
Kidney Stone Removed
Spleen Surgery
Colectomy - IBD
Kidney Transplant
Testicles Removed (Right, Left, Bi)
Gallbladder Removed
Ovaries Removed, Endometriosis
Hysterectomy, Fibroids
Coronary Artery Bypass
Ovaries Removed, Cyst
Hysterectomy, Uterine
PTCA
None
Other
CallaDerm
Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504
History and Intake Form (P.2)
Patient Name
Date of Birth
Skin Disease History (please check all that apply)
Acne
Dry Skin
Poison Ivy
Actinic Keratosis
Eczema
Abnormal Moles
Asthma
Flaking or Itchy Scalp
Psoriasis
Basal Cell Skin Cancer
Hay Fever / Allergies
Squamous Cell Skin Cancer
Blistering Sunburns
Melanoma
None
Other
Do you wear Sunscreen?
Yes
No
Do you tan in a tanning salon?
Yes
No
Do you have a family history of Melanoma?
Yes
No
If Yes, what SPF?
If Yes, which relative(s)?
Medications (Please list all current medications)
Do you take any type of blood thinner?
Yes
No
Do you take aspirin daily?
Yes
No
Are you allergic to Latex?
Yes
No
Are you allergic to Iodine or Betadine?
Yes
No
Allergies (Please list all allergies)
Social History (Please check all that apply)
Currently Smokes - Daily
Has Never Smoked
Currently Smokes - Not Daily
Drug Use
None
Has Smoked in the Past
CallaDerm
Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504
Review of Systems
Patient Name
Date of Birth
Do you have any of the following?
Pacemaker
Take Any Type of Blood Thinner
Defibrillator
Pregnant or Planning to get Pregnant
Artificial Joints Replaced within the past 2 Years
An Allergy to Lidocaine
Artificial Heart Valve
Experience Rapid Heartbeat with Epinephrine
Require Premedication Prior to Surgery
Experience Yeast Infections when taking Antibiotics
An Allergy to Adhesive
Experience G.I. Upset with Antibiotics
An Allergy to Topical Antibiotic Ointments
None
Are you currently experiencing any of the following?
Problems with Bleeding
A Cough
Problems with Healing
Depression
Problems with Scarring (Hypertrophic or Keloid)
Fever or Chills
Have any concern with Immunosuppression
Headaches
A Changing Mole
Hay Fever
A Rash (Diagnosed or Undiagnosed)
Joint Aches
Abdominal Pain
Muscle Weakness
Anxiety
Neck Stiffness
Bloody Stool
Night Sweats
Bloody Urine
Seizures
Blurry Vision
Sore Throat
Chest Pain
Thyroid Problems
Shortness of Breath
Unintentional Weight Loss
Wheezing
CallaDerm
Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504