History and Intake Form Name Email Date of Birth Past Medical History (Please Check All That Apply) Anxiety Athritis Asthma Atrial Fibrillation Bone Marraow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis High Blood Pressure HIV/AIDS High Cholesterol Thyroid Problems (Hyper-Hypo) Leukemia Lung Cancer lymphoma Prostate Cancer Radiation Treatment Seizures Stroke None Other (Please Specify) Skin Disease History (Please Check All That Apply) Acne Actinic Keratoses Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoroasis Squamous Cell Skin Cancer. None Other (Please Specify) Do You Wear Sunscreen? Yes No If Yes, What's the SPF? Do You Tan in a Tanning Salon? Yes No Do You Have a Family History of Melanoma? Yes No If Yes, Which relative(s)? Medications: (Please Enter All Current Medications) Drug Allergies: (Please Enter All Allergies) Cigarette Smoking: Currently Smokes Has Smoked in the Past Never Smoked Former Smoker Alerts: (Please Check All That Apply) Blood Thinners Defibrillator Pacemaker Are You Pregnant or Currently Trying to Get Pregnant? Other Family History of Skin Cancer, Eczema, Psoroasis, Acne (Only First Degree Relatives) Preferred Language: Race: *Ethnic Group: Hispanic Non Hispanic Preferred Pharmacy Name: Phone #: City or Zip Code: Referring Doctor: Submit
