"Medical Intake Form - Southwest Skin Specialists"

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Southwest Skin Specialists, Ltd. Medical Intake Form
Name: _____________________________________ Preferred Language: _________________ Date of Visit: ____________
 Prefer not to specify
Date of Birth: _______________ Place of Birth:_________________________ Ethnic Group:
 Hispanic or Latino
 Prefer not to specify
 Not Hispanic or Latino
Race:
 White  American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander
 Unknown 
 Asian  Black or African American
 Other: ___________________________
Primary Care Physician: ________________________________ Referred by: _____________________________________
Preferred Pharmacy: ________________________ Phone: ___________________ City or Zip code: ___________________
Please describe your skin problem(s) & reason for today’s visit: _______________________________________________
_______________________________________________________________________________________________________
Area(s) involved: _______________________________ How long have you had the problem(s): _____________________
Please check appropriate box (Y/N) as each applies to your CURRENT OR PAST MEDICAL HISTORY:
*Artificial heart valve / Infection Y N
Y N
Y N
Diabetes
Hyperthyroid
Y N
Y N
Y N
*Artificial joint (past 2 years)
High blood pressure
Hypothyroid
Y N
Y N
*Cold sores/herpes
Dementia
Y N
Autoimmune condition Y N
*Hepatitis, type: _______
Type: __________________________
Y N
*HIV/AIDS
*Organ transplant: ______________ Y N
Y N
Cancer
Type: __________________________
Y N
*Pacemaker/Defibrillator
(other than skin)
Y N
Y N
*Staph bacterial infection
Radiation treatment
When & why: ____________________
Y N
*MRSA infection
Y N
*Vasovagal reaction (fainting)
SURGICAL PROCEDURES (within the past 2 years): _______________
Y N
*Premedication prior to procedures
Antibiotic:________________
____________________________________________________________
Y N
*Accutane use in the last 6 months
Location(s)
*Have you had MELANOMA SKIN CANCER? Y N & date(s):_____________________________________________
Location(s)
Y N & date of most recent: ___________________________________
Have you had BASAL CELL CARCINOMA?
Location(s)
Have you had SQUAMOUS CELL CARCINOMA? Y N & date of most recent: ___________________________________
Y N
Do you wear Sunscreen? SPF __________
Has anyone in your FAMILY HAD MELANOMA? Y N Which relative(s): ______________________________________
Are you ALLERGIC to:
ALLERGIES TO MEDICATIONS:
SOCIAL HISTORY:
Y N
*Adhesive
Alcohol use:
Cigarette smoking:
__________________________________________________
Y N
 None
 Never smoked
*Epinephrine
Y N
 < 1 drink a day
 Former smoker
*Lidocaine
__________________________________________________
Y N
 1-2 drinks daily
 Currently smoke
*Antibiotic ointment
Y N
__________________________________________________
 3 or more per day
*Latex
List all CURRENT MEDICATIONS
(including chemotherapy, over-the-counter medications, vitamins, herbal supplements):
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS (Check any CURRENT SYMPTOMS or CONDITIONS):
Y N
*Problems w/bleeding/blood thinner Y N
*Pregnant
Y N
Y N Describe __________________________
*Planning pregnancy
Recent illness (past 3 months)
*Currently breastfeeding Y N
Y N
Abnormal blood counts
Y N
Y N
*Recent biologic med.
Abnormal scarring
Y N
Y N
*Recent chemotherapy
Enlarged lymph nodes
Y N
Y N
*Immunosuppression
Fever or chills
Patient
Signature _______________________________
Date _____________
Dr Initials _________ Staff Initials_________ v12.2015
Southwest Skin Specialists, Ltd. Medical Intake Form
Name: _____________________________________ Preferred Language: _________________ Date of Visit: ____________
 Prefer not to specify
Date of Birth: _______________ Place of Birth:_________________________ Ethnic Group:
 Hispanic or Latino
 Prefer not to specify
 Not Hispanic or Latino
Race:
 White  American Indian or Alaska Native  Native Hawaiian or Other Pacific Islander
 Unknown 
 Asian  Black or African American
 Other: ___________________________
Primary Care Physician: ________________________________ Referred by: _____________________________________
Preferred Pharmacy: ________________________ Phone: ___________________ City or Zip code: ___________________
Please describe your skin problem(s) & reason for today’s visit: _______________________________________________
_______________________________________________________________________________________________________
Area(s) involved: _______________________________ How long have you had the problem(s): _____________________
Please check appropriate box (Y/N) as each applies to your CURRENT OR PAST MEDICAL HISTORY:
*Artificial heart valve / Infection Y N
Y N
Y N
Diabetes
Hyperthyroid
Y N
Y N
Y N
*Artificial joint (past 2 years)
High blood pressure
Hypothyroid
Y N
Y N
*Cold sores/herpes
Dementia
Y N
Autoimmune condition Y N
*Hepatitis, type: _______
Type: __________________________
Y N
*HIV/AIDS
*Organ transplant: ______________ Y N
Y N
Cancer
Type: __________________________
Y N
*Pacemaker/Defibrillator
(other than skin)
Y N
Y N
*Staph bacterial infection
Radiation treatment
When & why: ____________________
Y N
*MRSA infection
Y N
*Vasovagal reaction (fainting)
SURGICAL PROCEDURES (within the past 2 years): _______________
Y N
*Premedication prior to procedures
Antibiotic:________________
____________________________________________________________
Y N
*Accutane use in the last 6 months
Location(s)
*Have you had MELANOMA SKIN CANCER? Y N & date(s):_____________________________________________
Location(s)
Y N & date of most recent: ___________________________________
Have you had BASAL CELL CARCINOMA?
Location(s)
Have you had SQUAMOUS CELL CARCINOMA? Y N & date of most recent: ___________________________________
Y N
Do you wear Sunscreen? SPF __________
Has anyone in your FAMILY HAD MELANOMA? Y N Which relative(s): ______________________________________
Are you ALLERGIC to:
ALLERGIES TO MEDICATIONS:
SOCIAL HISTORY:
Y N
*Adhesive
Alcohol use:
Cigarette smoking:
__________________________________________________
Y N
 None
 Never smoked
*Epinephrine
Y N
 < 1 drink a day
 Former smoker
*Lidocaine
__________________________________________________
Y N
 1-2 drinks daily
 Currently smoke
*Antibiotic ointment
Y N
__________________________________________________
 3 or more per day
*Latex
List all CURRENT MEDICATIONS
(including chemotherapy, over-the-counter medications, vitamins, herbal supplements):
_________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________
REVIEW OF SYSTEMS (Check any CURRENT SYMPTOMS or CONDITIONS):
Y N
*Problems w/bleeding/blood thinner Y N
*Pregnant
Y N
Y N Describe __________________________
*Planning pregnancy
Recent illness (past 3 months)
*Currently breastfeeding Y N
Y N
Abnormal blood counts
Y N
Y N
*Recent biologic med.
Abnormal scarring
Y N
Y N
*Recent chemotherapy
Enlarged lymph nodes
Y N
Y N
*Immunosuppression
Fever or chills
Patient
Signature _______________________________
Date _____________
Dr Initials _________ Staff Initials_________ v12.2015