Sonoma Skin Dermatology - 1 Appointment Date: 3/19/2013 Name: Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O

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Transcription:

Sonoma Skin Dermatology - Appointment Date: /9/0 Nickname: DOB: Age: Gender: Female Male Marital Status: S M D W O Spouse/Partner s SSN: DL# State: Home #: Work #: Cell Phone #: E-mail Address: Preferred Contact: Home- Work- Cell- Other Address: Preferred language: Pharmacy name: City: Fax Number: Emergency Contact: Relationship: Home #: Work #: Referral Source: Referring MD: Primary MD: Insurance Company: Insured Birth Date: Insurance ID# Insured Insured SSN: Whom may we thank for referring you?

Sonoma Skin Dermatology - Appointment Date: /9/0 Arrival Time: //900 Name Gender: AGE: Birth Date: City: Referral source: Primary MD: Chief Complaint today: Sun damaged skin/skin cancer check: Abscess or inflamed cyst: Acne: Cosmetic: Excessive Hair: Excessive Sweating: Hand Rash: Facial Rash: Hair Loss: Itching: A lesion or lesions that worry you: Nail Problem: Pigmentation Problem: Psoriasis: Rash: Rosacea: How long have you had this problem: Do you have any of the following today (please check all that apply): Rough spots: Y N Sores that won't heal: Y N Changing skin lumps or bumps: Y N New or changing moles: Y N Past History: Check those that apply healthy anemia anticoagulation therapy arthritis artificial heart valve asthma atrial fibrillation bipolar disorder bleeding after surgery bleeding with dental extraction Surgeries: no prior surgery appendectomy breast augmentation breast reconstructive surgery Cardiac bypass blood clot breast cancer cancer chronic hepatitis chronic steroid use Crohn's disease deep vein thrombosis dementia depression diabetes glaucoma Carotid surgery gall bladder surgery heart transplant hip replacement hysterectomy kidney removal glucose intolerance gout hay fever heart disease heart murmur HIV disease HIV positive high blood pressure high cholesterol hyperthyroidism hypothyroidism immune deficiency iron deficiency kidney stones kidney transplant knee replacement liver transplant lung transplant mastectomy pancreas transplant parathyroidectomy liver failure MRSA multiple drug pacemaker pulmonary embolism renal insufficiency require antibiotic for dental cleaning shingles stroke tuberculosis varicose veins Other: pilonidal cyst tonsillectomy thyroidectomy wisdom tooth extraction Other:

Sonoma Skin Dermatology - Cutaneous History: No significant history acne atopic dermatitis (eczema) cold sores dandruff Skin Cancer Risk Factors: None numerous moles drives a convertible fair skin blue eyes green eyes sunburns Sun Screen Use: Brand SPF Type Frequency Social History: Marital Status Education Occupation Language psoriasis recent history of Accutane rosacea keloid scars melasma numerous moles polycystic ovarian syndrome seborrheic dermatitis sensitive skin skin cancer lives in sunny climate personal history of MM lives at high altitude personal history of non melanoma skin cancer personal history of XRT personal history of precancerous spots sunbathing Skin Cancer History: Date Type Location Treatment Notes 6 7 8 9 sun damaged skin sun spots tinea pedis (athlete s foot) Other: tanning salon use personal history of weakened immune system family history MM Other:

Sonoma Skin Dermatology - Dietary Restrictions Alcohol Tobacco Recreational Drugs Hobbies Family History no significant family history adopted HEALTH CARE MAINTENANCE Shingle Vaccine Self Skin Exam Vitamin D Supplement alopecia areata asthma atopic dermatitis autoimmune disorders balding hay fever psoriasis Other: ROS please check if you are having of the following: Constitutional unexplained weight loss fever chills night sweats fatigue Eyes visual changes Ears, Nose, Mouth, Throat nose bleeds ear pain difficulty swallowing change in hearing sore throat Cardiovascular chest pain palpitations Respiratory shortness of breath wheezing cough sputum production Gastrointestinal nausea/vomiting abdominal pain blood in stool diarrhea constipation Genitourinary painful urination blood in urine GYN Pregnant/ nursing attempting to become pregnant undergoing infertility treatment heavy periods nipple discharge infertility irregular periods Musculoskeletal joint pain joint swelling Endocrine excessive urination excessive thirst excessive appetite weight gain Hematologic/ prolonged bleeding easy bruising swollen lymph nodes Lymphatic Neurological severe headaches depression anxiety Psychiatric Skin rough spots sores that won't heal skin lumps or bumps new or changing Allergies/ Immunologic moles allergic reactions to food allergic reaction to bee stings costume jewelry allergy

Sonoma Skin Dermatology - Height Weight Eye Color Response of your skin to the sun: I Always burns, never tans II Usually burns, does not tan well III Sometimes burns, tans easily IV Rarely burns, tans easily V Rarely burns, tans profusely VI Never burns, skin is dark Medications: (please include all including vitamins, mineral, hormones and topical therapies) Drug Dosage Doctor 6 7 8 9 0 Allergies Date Drug Reaction

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