HISTORY AND INTAKE FORM

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1 PATIENT NAME: HISTORY AND INTAKE FORM DOB: DATE: Asthma Atrial fibrillation Bone marrow transplantation Breast cancer Colon cancer COPD Coronary artery disease (heart disease) Diabetes End stage renal disease (kidney) Hepatitis (A, B, or C) Hypertension (high blood pressure) HIV / AIDS Hypercholesterolemia (high cholesterol) Artificial joints which joint/s: Basal cell carcinoma surgery Colectomy (inflammatory bowel disease) Coronary artery bypass Heart transplant PTCA (percutaneous transluminal coronary angioplasty) Kidney removed (right, left) Kidney transplant Acne Actinic keratoses (precancer lesions) Basal cell skin cancer Blistering sunburns Eczema Hay fever / allergies PAST MEDICAL HISTORY PAST SURGICAL HISTORY Hyperthyroidism (high thyroid level) Hypothyroidism (low thyroid level) Leukemia Lung cancer Lymphoma Pacemaker Prostate cancer Radiation treatment Rheumatoid arthritis Seizures Stroke Valve replacement Ovaries removed Prostate removed Mastectomy Melanoma surgery Spleen removed Squamous cell carcinoma surgery Hysterectomy; uterine cancer or fibroids SKIN DISEASE HISTORY Melanoma Precancerous moles (atypical moles) Psoriasis Squamous cell skin cancer Do you wear sunscreen? 9 Yes 9 No SPF #: Do you tan in a tanning salon? 9 Yes 9 No Do you have a family history of melanoma? 9 Yes 9 No If yes, which relative(s)? Any other pertinent family history? POS Reorder #

2 Referring Physician: Phone Number for Referring Physician: Primary Physician: Phone Number for Primary Physician: MEDICATIONS MEDICATION: DOSAGE: HOW OFTEN: REASON FOR TAKING: (Please PRINT all current medications) (Please enter all allergies) MEDICATIONS YOU ARE ALLERGIC TO SOCIAL HISTORY (Please circle all that apply) Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily - if yes, how many? Alcohol use: Less than one drink per day One to two drinks per day Three or more drinks per day What is your occupation? Pharmacy Name: Address: POS Reorder #

3 PATIENT REGISTRATION (Please Print) DATE: PATIENT INFORMATION Patient s Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Male 9 Female 9 Age: Patient s Date of Birth: Home ( ) Cell ( ) Address: Marital Status: Married 9 Single 9 If Married, Name of Spouse: If Child - Name of Mother and Father or Legal Guardian: Person Responsible for bill if different than patient: Name: SS #: (First) (Middle) (Last) Street Address: Apt. #: Home ( ) Cell ( ) D.O.B. Age: Primary Insurance Name of Insurance: Subscriber Name: INSURANCE INFORMATION Secondary Insurance Name of Insurance: Subscriber Name: Subscriber s Date of Birth: Sex: Subscriber s Date of Birth: Sex: Policy or ID #: Policy or ID #: Group #: Group #: POS Reorder #

4 ANNUAL MEDICAL CONSENT The patient is responsible for providing this office with the correct insurance information, a CURRENT REFERRAL for the services that are to be performed, and any insurance updates. I understand the above statement and agree that I will be responsible for the total charges incurred if I fail to comply with this request, including any charges not covered by my insurance. I authorize Drs. Jeffrey P. Callen, Carol L. Kulp-Shorten, Jyoti B. Burruss, Kristin O. Donovan, Shannon M. McAllister, Alfred L. Knable, Timothy S. Brown, Anna A. Hayden, Cindy E. Owen, Courtney R. Schadt, Sonya K. Burton, Michael W. McCall, Jr., M. Tye Haeberle, and nurse practitioners Susan E. Elrod, Bridget G. Hart, Kathryn A. West-Pfingston and physicians assistants Elizabeth Morton and Mitzi Carter to release information for the purpose of payment, treatment and routine healthcare operations and including medical research studies. I authorize payment of medical benefits to Drs. Jeffrey P. Callen, Carol L. Kulp-Shorten, Jyoti B. Burruss, Kristin O. Donovan, Shannon M. McAllister, Alfred L. Knable, Timothy S. Brown, Janine C. Malone, Anna A. Hayden, Soon Bahrami, Cindy E. Owen, Courtney R. Schadt, Sonya K. Burton, Michael W. McCall, Jr., M. Tye Haeberle, and nurse practitioners Susan E. Elrod, Bridget G. Hart, Kathryn A. West-Pfingston and physicians assistants Elizabeth Morton and Mitzi Carter. Pursuant to Kentucky Revised Statutes (KRS ), if your account requires the use of an attorney to recover the amount you owe, either by legal action or by other means, you will be responsible for payment of reasonable attorney fees and court costs. Further, if we are required to turn your account over to a collection agency, you will be responsible for those charges as well. All medical records created, sent or received by this office in connection with the services to be performed will be stored and maintained in an electronic form. Upon conversion of any paper or other record to an electronic form, the original record will be discarded through shredding or other permanent disposal. I understand the above statement and agree that my medical records can be stored and maintained electronically. X (signature) (date) POS Reorder #

5 ASSOCIATES IN DERMATOLOGY, PLLC RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT I have received a copy of the Privacy Practices provided by Associates in Dermatology, PLLC. Print Patient s Name Date of Birth Signature of Patient / Parent or Guardian Date My Protected Health Information may be disclosed to: 9 Self 9 Spouse / Significant Person Responsible for bill if different than patient: 9 Parent / Guardian 9 Roommate 9 9 Children I give permission for Associates in Dermatology to contact or leave a message regarding test results on the following: 9 Home Phone Voice Mail Home # 9 Cell Phone Voice Mail Cell # 9 Work Phone Voice Mail Work # PHARMACY MEDICATION HISTORY RELEASE Please initial below if Associates in Dermatology has permission to pull your pharmacy fill history. (initials) POS Reorder #

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