TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU.

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NEW PATIENT FORM TO SERVE YOU MORE EFFICIENTLY, PLEASE COMPLETE THIS FORM AND RETURN IT TO THE FRONT DESK BEFORE YOU ARE CALLED TO AN EXAM ROOM. THANK YOU. DATE: ACCOUNT NUMBER: AGE: NAME: DATE OF BIRTH: PHARMACY NAME AND ZIP CODE: SELECT ANY OF THE FOLLOWING MEDICAL CONDITIONS YOU CURRENTLY HAVE: NONE Anxiety Artificial Joints Asthma Atrial Fibrillation (irregular heartbeat) BPH Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression End Stage Renal Disease Gerd Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Pacemaker Prostate Cancer Radiation Treatment Seizures Stroke Valve Replacement Other (please specify) PAST SURGERIES ON THE FOLLOWING ORGANS: NONE Appendix Breast Mastectomy: Both Right Left Breast Lumpectomy: Both Right Left Breast Biopsy Breast Reduction Breast Implants Colon Surgery (Colectomy) for: Resection Diverticulitis Inflammatory Bowel Disease Gall Bladder Surgery (Cholecystectomy) Heart: Coronary Artery Bypass Surgery PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Knee Joint Replacement: Both Right Left Hip Joint Replacement: Both Right Left Joint Replacement within the last 2 years Kidney: Biopsy Nephrectomy Kidney Stone Removal Transplant Ovaries (Oophorectomy): Ovarian Cyst Endometriosis Ovarian Cancer Prostate (Prostatectomy): Prostate Cancer Biopsy Other (Please specify):

2. HAVE YOU HAD ANY OF THE FOLLOWING SKIN CONDITIONS? NONE Acne Actinic Keratosis Asthma Basal Cell Carcinoma Blistering Sunburn Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer Other (Please specify): Do you wear sunscreen? Yes No If yes, what SPF? Do you tan in a tanning salon? Yes No FOR THE PROBLEM(S) YOU ARE SEEKING HELP WITH TODAY, SELECT ANY OF THE FOLLOWING SKIN CONDITIONS THAT YOU ARE CURRENTLY EXPERIENCING. Acne Blister Bruise Cyst Growth Hair Loss Infection Itch Lesion Rash Rough Spot(s) Sore Ulcer Wart Where is your problem(s) located? How severe is your problem(s)? Mild Moderate Severe Approximately how long have you had this/these problem(s)? Years Months Weeks Days What symptom do you have with this condition? Chills Cough Diarrhea Fever Household contact with similar rash Recent Illness Sore Throat Starting A New Medication None Are you currently treating your problem? Yes No If yes, please specify how If your new problem(s) is a growth, how would you describe it? Asymmetric (one side is different from the other) Bleeding Catching On Clothes Changing Color Darkening Enlarging Irregular Itchy New Painful Purulent (with pus) Scaly Spreading Swollen

3. FAMILY HISTORY Do you have a family history of Melanoma? Yes No If yes, which relative? Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other (Please Specify: SURGICAL HISTORY Have you ever had difficulty stopping bleeding? Yes No Do you require Antibiotics prior to a surgical procedure? Yes No Have you had an artificial joint replacement? Yes No If yes, when and where? Do you have an artificial heart valve? Yes No Do you have a pacemaker? Yes No Do you have a defibrillator? Yes No SMOKING HISTORY Do you currently smoke? Yes No If yes, do you smoke: Every Day or Some Days If no, have you ever smoked in the past? Yes No PREGNANCY Are you pregnant or currently trying to get pregnant? Yes No

4. CURRENT MEDICATIONS (LIST ONE PER LINE PLEASE ASK AT FRONT DESK FOR ADDITIONAL FORM IF NEEDED): NONE: 1) Name: Dose: Frequency: Started: 2) Name: Dose: Frequency: Started: 3) Name: Dose: Frequency: Started: 4) Name: Dose: Frequency: Started: 5) Name: Dose: Frequency: Started: 6) Name: Dose: Frequency: Started: 7) Name: Dose: Frequency: Started: 8) Name: Dose: Frequency: Started: 9) Name: Dose: Frequency: Started: 10) Name: Dose: Frequency: Started: MEDICATION ALLERGIES (LIST ONE PER LINE PLEASE ASK AT FRONT DESK FOR ADDITIONAL FORM IF NEEDED): NONE: 1) Name: Other 2) Name: Other 3) Name: Other 4) Name: Other

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