dermatology assoc of mclean form 06092016-3
TRANSCRIPT
PATIENTINFORMATION:
Name:______________________________________________________ DOB(mm/dd/yy):______/______/______
Email:__________________________ PharmacyName&Phone:_________________________/___________________PASTSKINHISTORY:(pleasecircleallthatapply)
Historyofnon-melanomaskincancer?YesNo Ifyes,type(s)andlocation(s)_______________________________
Historyofmelanoma?YesNo Ifyes,locationandyear__________________________________
Familyhistoryofmelanoma?YesNo Ifyes,relationship?______________________________________LISTOFMEDICATIONS/SUPPLEMENTS:(pleaselistdosageandfrequency)Medication(s)/Supplement(s): Dosage: Frequency:
1.____________________________ __________________________ ___________________________
2.____________________________ __________________________ ___________________________
3.____________________________ __________________________ ___________________________
4.____________________________ __________________________ ___________________________
5.____________________________ __________________________ ___________________________
6.____________________________ __________________________ ___________________________
7.____________________________ __________________________ ___________________________
8.____________________________ __________________________ ___________________________USEOFNARCOTICS:(pleasecircleallthatapply)Yes No If"Yes",doyourequireastoolsoftener?: Yes NoALLERGIES:MedicationAllergies:(pleaselist)
1._____________________________________________ 3._____________________________________________
2._____________________________________________ 4._____________________________________________
Latex: Yes No
HaveyoueverhadPoisonIvy: Yes NoSOCIALHISTORY:
Doyouusetobacco: Yes No Formersmoker
If"Yes": Currenteverydaysmoker Currentsomedaysmoker
DoyouconsumeAlcohol?: Yes No
If"Yes": Lessthan1drinkperday 1-2drinksperday 3ormoredrinksperday
VACCINATIONHISTORY:
FluVaccination(thisyear): Yes No
Pneumococcal(Pneumonia)Vaccination: Yes No
*Howmanytimesinthepastyearhaveyouhad5ormoredrinksinadayformen,or4ormoredrinksinadayforwomenoranyadultsolderthan65?(pleasecircle)012345+
PLEASECHECKIF"YES":☐ Allergytoadhesive ☐ BloodThinners ☐ Rapidheartbeatwithepinephrine
☐ Allergytolidocane ☐ MRSA ☐ Pregnancyorplanningapregnancy
☐ Allergytotopicalantibiotic/ointments ☐ Defibrillator ☐ WestAfrica:TravelorContact
☐ Artificialheartvalve ☐ Pacemaker ☐ TraveltoEbolariskcountry
☐ Artificialjointsinthepasttwoyears ☐ PremedicationpriortoproceduresPASTMEDICALHISTORY(Selectanyofthefollowingmedicalconditionsthatyoucurrentlyhave):☐ None ☐ CoronaryArteryDisease ☐ Hyperthyroidism
☐ Anxiety ☐ Depression ☐ Hypothyroidism
☐ Arthritis ☐ Diabetes(LastHemoglobinA1C_____) ☐ Leukemia
☐ Asthma ☐ EndStageRenalDisease ☐ LungCancer
☐ AtrialFibrillation(IrregularHeartbeat) ☐ GERD ☐ Lymphoma
☐ BoneMarrowTransplant ☐ HearingLoss ☐ ProstateCancer
☐ BPH ☐ Hepatitis ☐ RadiationTreatment
☐ BreastCancer ☐ Hypertension ☐ Seizures
☐ ColonCancer ☐ HIV/AIDS ☐ Stroke
☐ COPD ☐ Hypercholesterolemia ☐ Other:_______________PASTSURGERIES:☐ None ☐ Liver:LiverTransplant
☐ Appendix(Appendectomy ☐ Liver:Shunt
☐ Bladder(Cystectomy) ☐ Ovaries(Oophorectomy):Endometriosis
☐ Breast:BreastBiopsy ☐ Ovaries(Oophorectomy):OvarianCancer
☐ Breast:LumpectomyRL ☐ Ovaries(Oophorectomy):OvarianCyst
☐ Breast:MastectomyRL ☐ Ovaries(Oophorectomy):TubalLigation
☐ Colon(Colectomy):ColonCancerResection ☐ Pancreas:Pancreatectomy
☐ Colon(Colectomy):InflammatoryBowelDisease ☐ Prostate(Prostatectomy):ProstateBiopsy
☐ Colon:Colostomy ☐ Prostate(Prostatectomy):ProstateCancer
☐ Gallbladder:(Cholecystectomy) ☐ Prostate(Prostatectomy):TURP
☐ Heart:BiologicalValueReplacement ☐ Rectum:APR
☐ Heart:CoronaryArteryBypassSurgery ☐ Rectum:LowAnteriorResection
☐ Heart:HeartTransplant ☐ Skin:BasalCellCarcinoma
☐ Heart:MechanicalValueReplacement ☐ Skin:Melanoma
☐ Heart:PTCA ☐ Skin:SkinBiopsy
☐ JointReplacement:HipLR ☐ Skin:SquamousCellCarcinoma
☐ JointReplacement:KneeLR ☐ Spleen(Splenectomy)
☐ Kidney:KidneyBiopsy ☐ Testicles(Orchiectomy)
☐ Kidney:KidneyStoneRemoval ☐ Uterus(Hysterectomy):Fibroids
☐ Kidney:KidneyTransplant ☐ Uterus(Hysterectomy):UterineCancer
☐ Kidney:Nephrectomy ☐ Uterus(Hysterectomy):CervicalCancer
☐ Liver:Hepatectomy ☐ Other:____________________________________