Please note that it is important to fill in all the fields before submitting. Thank you.

*Patient’s : Last name :		Middle name :		*First name :
I prefer to be called :			Occupation :
REFFERRED BY :			Hobbies :

General Medical History: Do you have or have you ever had any of the following?
Yes No Anxiety Yes No Arthritis Yes No Asthma Yes No Atrial fibrillation Yes No BPH Yes No Bone Marrow Transplantation Yes No Breast Cancer Yes No Colon Cancer Yes No COPD Yes No Coronary Artery Disease Yes No Depression Yes No Diabetes	Yes No End Stage Renal Disease Yes No GERD Yes No Hearing Loss Yes No Hepatitis Yes No Hypertension Yes No HIV/AIDS Yes No Hypercholesterolemia Yes No Hyperthyroidism Yes No Hypothyroidism Yes No Leukemia Yes No Lung Cancer Yes No Lymphoma	Yes No Pacemaker Yes No Prostate Cancer Yes No Radiation Treatment Yes No Seizures Yes No Stroke Yes No Valve Replacement Yes No None Yes No Other :

Surgeries:

Yes No Appendix Removed Yes No Bladder Removed Yes No Mastectomy ( Right Left Bilateral ) Yes No Lumpectomy ( Right Left Bilateral ) Yes No Breast Biopsy ( Right Left Bilateral ) Yes No Breast Reduction Yes No Breast Implants Yes No Colectomy : Colon Cancer Resection Yes No Colectomy : Diverticulitis Yes No Colectomy : IBD Yes No Gallbladder Removed Yes No Coronary Artery Bypass Yes No PTCA Yes No Mechanical Valve Replacement Yes No Biological Valve Replacement Yes No Heart Transplant Yes No Joint Replacement, Knee ( Right Left Bilateral ) Yes No Joint Replacement, Hip ( Right Left Bilateral ) Yes No Joint Replacement within last 2 years Yes No Kidney Biopsy Yes No Kidney Removed ( Right Left )

Yes No Kidney Stone Removed Yes No Kidney Transplant Yes No Ovaries Removed : Endometriosis Yes No Ovaries Removed : Cyst Yes No Ovaries Removed : Ovarian Cancer Yes No Prostate Removed : Prostate Cancer Yes No Prostate Biopsy Yes No TURP Yes No Skin Biopsy Yes No Basal cell Cancer Surgery Yes No Squamous Cell Carcinoma Surgery Yes No Melanoma Surgery Yes No Spleen Removed Yes No Testicles Removed ( Right Left Bilateral ) Yes No Hysterectomy : Fibroids Yes No Hysterectomy : Uterine Cancer Yes No None Yes No Other :

Skin Type: If 1st exposed to the sun in the summer without sunscreen, would you:

1. always burn, never tan 2. always burn, sometimes tan 3. sometimes burn, always tan gradually 4. burn minimally, always tan well 5. rarely burn, tan profusely 6. never burn, deeply pigmented Yes No Acne Yes No Actinic Keratoses Yes No Asthma Yes No Basal Cell Skin Cancer Yes No Blistering sunburns Yes No Dry Skin Yes No Eczema Yes No Flaking or itchy Scalp Yes No Hay Fever/Allergies Yes No Melanoma Yes No Poison Ivy Yes No Precancerous Moles Yes No Psoriasis Yes No Squamous Cell Skin Cancer Yes No None Yes No Other

Do you wear Sun Screen : Yes No      If yes, what SPF ?      Do you tan in a tanning salon ? Yes No

Family History: Select any conditions affecting a blood relative. Specify who is affected.

Melanoma Which relative(s) : Basal cell or squamous cell skin cancer Which relative(s) : Psoriasis Which relative(s) : Eczema Which relative(s) : Asthma Which relative(s) : Hay fever or allergies Which relative(s) : Acne Which relative(s) :

Any other family history :

Female Patients :
Yes No Are you pregnant or breast feeding? If not, method of birth control: Yes No Tubal ligation (tubes tied) Yes No Hysterectomy - uterus onlyuterus and ovaries	Yes No Are you contemplating pregnancy? If yes, when: Yes No Yeast infections when taking antibiotics

Other Medical Problems or Surgeries:
Allergies to medications and type of allergic reaction (example: hives, difficulty breathing, swelling)
Medications (Prescription, Non-Prescription, Vitamins, Herbs):

Social History :

Cigarette Smoking :  Please Select Never Smoked Quit : Former smoker Smokes less than daily Smokes daily Sexual History :  Please Select Not sexually active Sexually active with one partner Sexually active with more that one partner Same sex partner Illicit Drug Use :  Please Select Drug Use IV Drug Use Alcohol use :  Please Select None Less than I drink a day 1-2 drinks a day 3 or more drinks a day Safety :  Please Select I feel safe at home I do not feel safe at home Other :

*Signature of person filling out this form :		Today’s date :