F M S M W D. Age Birth Date Gender Marital Status Cell Phone

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1 MIDWEST DERMATOLOGY CLINIC, PC Patient Legal Name Last First Middle Initial Today s Date Mailing Address Street City and State Zip Home Telephone F M S M W D. Age Birth Date Gender Marital Status Cell Phone Race Ethnicity Preferred Language Social Security # Address Employer s Name and Address Street City and State Zip Business Telephone Patient s Occupation Emergency Contact other than Spouse Emergency Telephone SPOUSE OR RESPONSIBLE PARTY INFORMATION. Responsible Party/Spouse Name Birth Date Social Security No Relationship to Patient Street Address City and State Zip Code Home Telephone Responsible Party/Spouse Occupation PRIMARY INSURANCE COMPANY Responsible Party/Spouse Employer INSURANCE INFORMATION. Insurance Company Name Policy Holder Name Date of Birth Employer SECONDARY INSURANCE COMPANY: Insurance Company Name Policy Holder Name Date of Birth Employer REFERRALINFORMATION. REFERRAL BY A FRIEND OR FAMILY MEMBER Name Relationship Update 10/30/2015

2 Midwest Dermatology Clinic, PC History and Intake Form Patient Name: Date: In the event that we are unable to reach you directly, can we leave a detailed message on your phone? YES NO Pharmacy Name: Located at or near: City Primary Care Physician: Address: Referring Physician: Address: Past Medical History: (please circle all that apply) Anxiety Arthritis Asthma Atrial fibrillation Bone Marrow Transplant Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss High Blood pressure High Cholesterol Hyper-THYROID Hypo - THYROID Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Other Past Surgical History: (please circle all that apply) Joint Replacement, Knee (Right, Left, Bilateral) Year Joint Replacement, Hip (Right, Left, Bilateral) Year Heart Transplant Kidney Transplant Hysterectomy Other PLEASE TURN OVER TO CONTINUE WITH MEDICAL HISTORY

3 Patient Name Skin Disease History: (please circle all that apply) Dry Skin Acne Eczema Actinic Keratosis Flaking or Itchy Scalp Asthma Hay Fever/Allergies Basal Cell Skin Cancer Melanoma Blistering Sunburns Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Other Do you wear Sunscreen? Yes No If yes, what 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: May we transfer (import) medication list from Pharmacy - yes / no. Please print all current medications or provide a typed list. Allergies to Medications Please list Social History: (Please circle all that apply) Cigarette Smoking: Currently Smokes Has smoked in the past Never smoked Alcohol Use: None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day Family Medical History (Only first degree relatives)

4 MIDWEST DERMATOLOGY CLINIC, PC Patient Name: Date: Doctor Surgeries past year? May we transfer (import) Medication List- yes / no - list Current medications Medications you need refilled this visit New Allergy since last visit Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for each of the following) Symptom Yes OR No Problems with bleeding Problems with healing Problems with scarring Rash Immunosuppression Thyroid problems Joint Aches Other Symptoms: ALERTS: (please check yes or no for all that apply) Yes NO Allergy to Adhesive Allergy to Latex Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement in last 2 Years Blood thinners Defibrillator Hepatitis HIV MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heartbeat with epinephrine TB Are you pregnant or currently trying to get pregnant? Updated 8/29/17

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