Michael J. Huether, M.D., P.C. Arizona Skin Cancer Surgery Center, P.C. History and Intake Form. Patient Name D.O.

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1 Past Medical History: (please mark the medical conditions that you currently have) Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke Past Surgeries: (please check mark all past surgeries) Appendix (Appendectomy) Bladder (Cystectomy) Breast: Breast Biopsy R/L Breast: Lumpectomy B/R/L Breast: Mastectomy B/R/L Date: Colon Cancer Resection Date: Colon (Colectomy) Date: Colon: Colostomy Date: Gallbladder (Cholecystectomy) Heart: Valve Replacement Heart: Bypass Surgery Heart: Heart Transplant Heart: PTCA Joint Replacement: Hip/Knee - B/L/R Date: Kidney: Stone Removal Kidney: Transplant Date: Kidney: Nephrectomy/Biopsy Liver: Hepatectomy/Shunt Liver: Transplant Date: Ovaries (Oophorectomy): Endometriosis/Cancer/Cyst Date: Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate (Prostatectomy): Prostate (Prostatectomy): TURP Rectum: Skin : Biopsy/Surgery Spleen (Splenectomy) Testicles (Orchiectomy) Uterus (Hysterectomy)

2 Skin Disease History: (please check mark all the skin conditions that you have had) Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Do You Wear Sunscreen? Yes No If yes what SPF? Do You Tan In a Tanning Salon? Yes No Family History Do You Have a Family History of Skin Cancer? Yes No if yes what Type? Which Relative? Pertinent Family History (Only first degree relatives): Allergies: (please enter all allergies and reactions or attach a list)

3 Social History: (please check all that apply) Current Height: Weight: Occupation/Former Occupation: Smoking Status: Never smoker Former Smoker Current Every Day Smoker Date Start/Quit: #Packs Per Day for how many years: Alcohol Status: none Less Than 1 Drink Per Day 1-2 Drinks Per Day 3 or More Drinks Per Day What is your caffeine intake: How often do you exercise: Patient Feels Safe at Home Patient Drives in the Daytime Patient Feels Unsafe at Home Patient Drives at Night Review of Systems/Alerts: (please check all that apply) Problems With Healing Hypertension Irregular Heart Beat Anxiety/Depression Ebola: Traveled To Country Ebola Transmission in the Last 21 Days, contact with Ebola Patient, Headaches, Weakness, Muscle Pain, Vomiting, Diarrhea, Rash Hay Fever Chest Pain Fever or Chills Night Sweats Unintentional Weight Loss Thyroid Problems Sore Throat Blurry Vision Abdominal Pain Bloody Stool Bloody Urine Joint Aches/Muscle Weakness Seizures Cough/Shortness of Breath/Wheezing

4 Alerts: (please check all that apply) Allergy to Adhesive Allergy to Local Anesthetic Allergy to Latex Artificial Heart Valve Artificial Joints Within Past 2 Years Premedication Prior to Procedures Blood Thinners Problems With Bleeding Problems With Scarring (hypertrophic or keloid) Immunosuppression (transplant/chemotherapy/medicat ion) HIV Hepatitis B or C MRSA Defibrillator or Pacemaker Oxygen Use (#liters/demand or continuous) Allergy to Topical Antibiotic Ointment Rapid Heart Beat With Epinephrine Pregnancy or Planning Have you had your pneumonia vaccine? Yes No Do you get the flu vaccine? Yes No

5 S:\Office Forms\Patient Handouts\Patient Medication list.docx Name: Birth date: Michael J. Huether, M.D. Medication List Name of Medication Dosage How often Reviewed: Date: S:\Office Forms\Patient Handouts\Patient Medication list.docx

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