Name: Street Address: City / State: Zip Code: Date of Birth: Gender: Marital Status: Single Married Divorced Widowed Preferred Language: Race: Ethnicity (Hispanic/Latino): Yes No Email Address: Home Number ( if preferred): Cell Number ( if preferred): Emergency Contact (Name, Relation, Phone #): Name of Insurance Holder: Date of Birth (Ins. Holder): Relationship of Insurance holder to patient: How did you hear about us? Occupation and Workplace: Primary Care Physician Referring Physician (if not PCP) Name: Address: Phone number: Name: Address: Phone number: Preferred Pharmacy Mail Order Pharmacy (If used) Name: Phone Number: City or Zip Code: Name: Phone Number: City or Zip Code:
Past Medical History Select any of the following medical conditions you currently have: Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH (Prostate) Breast Cancer Colon Cancer COPD Coronary Artery Disease (CAD) Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV / AIDS Hypercholesterolemia Hyperthyroidism Hypothyroidism Irritable Bowel Syndrome Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke NONE Family Medical History Select any of the following medical conditions your first degree relatives have (Mother, Father, Brother, Sister, Child): Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH (Prostate) Breast Cancer Colon Cancer COPD Coronary Artery Disease (CAD) 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 NONE
Past Surgical History Have you had any surgeries on the following list? Appendix (Appendectomy) Bladder (Cystectomy) Breast: Breast Biopsy Breast: Lumpectomy (Right, Left, Bilateral) Breast: Mastectomy (Right, Left, Bilateral) Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Diverticulitis Colon (Colectomy): Inflammatory Bowel Disease Colon: Colostomy Gallbladder (Cholecystectomy) Heart: Coronary Artery Bypass Surgery Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA Joint Replacement: Hip (Right, Left, Bilateral) Joint Replacement: Knee (Right, Left, Bilateral) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Kidney: Kidney Transplant Kidney: Nephrectomy Liver: Hepatectomy Liver: Liver Transplant Live: Shunt Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy): Ovarian Cancer Ovaries (Oophorectomy): Ovarian Cyst Ovaries: Tubal Ligation Pancreas: Pancreatectomy Prostate (Prostatectomy): Prostate Biopsy Prostate (Prostatectomy: Prostate Cancer Prostate (Prostatectomy): TURP Rectum: APR Rectum: Low Anterior Resection Skin: Basal Cell Carcinoma Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen (Splenectomy) Testicles (Orchiectomy) Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer Uterus (Hysterectomy): Cervical Cancer NONE CONTINUED ON OTHER SIDE
Skin Disease History Have you had any of the following? Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Have Fever / Allergies Melanoma Poison Ivy Precancerous Moles Psoriasis Squamous Cell Skin Cancer NONE Do you wear Sunscreen? Yes No 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 If yes, what SPF? Do you tan in a tanning salon? Yes No
Medications List all current medications, or give your list to your Medical Assistant. Please include dose (amount), frequency (how often) and reason for taking (disease): Allergies List all allergies and reactions if known, or give your list to your Medical Assistant: Social History Smoking Status (please choose one): Current every day smoker Current someday smoker Former smoker Never smoker Unknown if ever smoked Start Smoking: mm/dd/yyyy Quit Smoking: mm/dd/yyyy Number of Packs Per Day: Total Years Smoking: Alcohol Intake (please choose one): None 1 or less per day 1-2 per day 5 or more per day Driving Status: Drives in the Daytime Drives at Night How often do you exercise? Unspecified Several times a day Once a day A few times a week A few times a month Never What is your caffeine use? Unspecified Several times a day Once a day A few times a week A few times a month Never CONTINUED ON OTHER SIDE
Review of Systems Please check yes or no for the following symptoms that apply to you today: Symptom Yes No Dizziness or Lightheadedness Nausea or Vomiting Headaches GI Upset with Antibiotics Excessive Fatigue Mood Changes or Depression Suicide Ideation Problems with Bleeding Problems with Healing Immunosuppression Changing Mole Rash Abdominal Pain Anxiety Bloody Stool Bloody Urine Vision Changes Chest Pain Cough Fever or Chills Hay Fever Joint Aches Shortness of Breath Unintentional Weight Loss Pruritus
Alerts Please check yes or no for the following that apply to you today: Symptom Yes No Pregnant Planning Pregnancy Breastfeeding Pacemaker Defibrillator Artificial Joints (within the past two years) Artificial Heart Valve Allergy to Latex Allergy to Adhesive Allergy to Lidocaine Premedication Prior to Procedures Allergy to Topical Antibiotic Ointments Blood Thinners Yeast Infections with Antibiotics Problems with Scarring (hypertrophic or keloid) History of Melanoma History of Non Melanoma Skin Cancer Family History of Melanoma Family History of Non Melanoma Skin Cancer MRSA Had FLU Vaccination? Had Pneumonia Vaccination?
Dermatology Specialists of Canton 285 North Lilley Road Canton, MI 48187 Ph: (734) 495-1506 Patient Financial Responsibility Thank you for choosing Dermatology Specialists of Canton as your provider for dermatology care. We strive to provide the most efficient and patient-friendly skin care to all our patients. In an effort to provide the best care, it is important that you read the financial responsibility form below. -Please inform the front office staff if your insurance plan has changed (active/inactive), if you have received a new insurance card, or if you do not have insurance currently. -Copayments and past due balances are due following your visit for that day. If you do not have insurance or a referral, you will be responsible for the full charged amount of your visit. -There are certain fees associated with requesting copies of medical records. Please ask the office staff to clarify the cost of a medical record request. -Medicare insurance patients will be given an Advanced Beneficiary Notice (ABN) form if a service is not covered by our office. It is your responsibility to sign the ABN for that particular service. -Cash, personal check, debit, and credit cards (Visa, MasterCard, American Express, and Discover) are acceptable forms of payment. CONSENT TO EXAMINATION AND TREATMENT: I understand and voluntarily consent to receive medical and health care services given by Dermatology Specialists of Canton, a Hamzavi Dermatology and Ali A. Berry MD PC Practice, and will be referred to as DSC for the remainder of this document. I understand the examination procedures will be explained to me and I authorize the administration of all diagnostic and therapeutic procedures, examinations and treatments considered advisable or necessary in the judgment of the physician. I understand that the examination results will be provided to me with recommendations. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments. The responsibility for any follow up examinations to check abnormalities found and treated, lies with me and not with DSC. I hereby release my examiner from all responsibility in connection with the examination. I understand that in order for the doctor to give me the best medical care possible, I must follow instructions and notify the office if I have problems with my medications or treatment. CANCELLED OR MISSED APPOINTMENTS: We are happy to reschedule any appointment for you. We do request Twenty-four (24) hour notice of cancellation. It is our aim to accommodate you the patient. We have patients eager to use your canceled appointment time. We reserve the right to charge a cancellation fee of twenty five dollars ($25) for appointments not canceled 24 hours in advance. We hope you, our valued patient, will cooperate in this simple request. FOR PROCEDURE APPOINTMENTS: We require 48 hour notice for procedure appointments if you need to reschedule or cancel. These appointments include but are not limited to: complete skin examinations, biopsies, excisions, and cosmetic procedures. For procedure appointments not canceled 48 hours in advance you will be charged a fifty dollar ($50) fee. You will be asked to sign a copy of this agreement during your visit to Dermatology Specialists of Canton.