NAME DATE Page 1. Other. Kidney Removed (Right, Left) Bladder Removed. Ovaries Removed for Endometriosis Breast Biopsy

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NAME DATE Page 1 Past Medical History: (please circle ALL that apply) Anxiety Hepatitis Arthritis Hypertension Artificial joints HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism Benign Prostatic Hypertrophy Hypothyroidism Bone Marrow Transplantation Leukemia Breast Cancer Lung Cancer Colon Cancer Lymphoma Chronic Obstructive Pulmonary Disease Pacemaker Coronary Artery Disease Prostate Cancer Depression Radiation Treatment Diabetes Seizures End Stage Renal Disease Stroke Gastro-Esophageal Reflux Disease Hearing Loss NONE (PLEASE CIRCLE IF NONE APPLY) Other Past Surgical History: (please circle ALL that apply) Appendix Removed Kidney Removed (Right, Left) Bladder Removed Kidney Stone Removal Mastectomy (Right, Left, Bilateral) Kidney Transplant Lumpectomy (Right, Left, Bilateral) Ovaries Removed for Endometriosis Breast Biopsy Ovaries Removed for Cyst Breast Reduction Ovaries Removed for Ovarian Cancer Breast Implants Prostate Removed for Prostate Cancer Colectomy for Colon Cancer Resection Prostate Biopsy Colectomy for Diverticulitis Trans-Urethral Resection of Prostate Colectomy for Inflammatory Bowel Disease Skin Biopsy Gallbladder Removed Basal Cell Cancer Surgery Coronary Artery Bypass Squamous Cell Carcinoma Surgery Percutaneous Transluminal Coronary Melanoma Surgery Angioplasty Spleen Removed Mechanical Valve Replacement Testicles Removed Biological Valve Replacement Hysterectomy for Fibroids Heart Transplant Hysterectomy for Uterine Cancer Joint Replacement, Knee (Right, Left, Both) Joint Replacement, Hip (Right, Left, Both) NONE (PLEASE CIRCLE IF NONE APPLY) Kidney Biopsy Other

Page 2 Skin Disease History: (please circle ALL that apply) Acne Hay Fever/Allergies Actinic Keratoses Melanoma Asthma Poison Ivy Basal Cell Skin Cancer Precancerous Moles Blistering Sunburns Psoriasis Dry Skin Squamous Cell Skin Cancer Eczema Flaking or Itchy Scalp NONE (PLEASE CIRCLE IF NONE APPLY) Other Skin Diseases You Have Had 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)? Any other family history of skin diseases? Medications: (Please enter ALL current medications) PLEASE CIRCLE IF NONE Allergies: (Please enter ALL allergies) PLEASE CIRCLE IF NONE

Social History: (Please circle all that apply) Page 3 Illicit Drug Use: (PLEASE CIRCLE IF APPLICABLE) Drug Use IV Drug Use Alcohol Use: (PLEASE CIRCLE ONE) Alcohol: none Alcohol: less than 1 drink a day Alcohol: 1-2 drinks a day Alcohol: 3 or more drinks a day Other Cigarette Smoking: (PLEASE CIRCLE ONE) Smoke every day Smoke less than daily Former smoker Never smoked Smoker, current status unknown Unknown if ever smoked

Review of Systems: Do any of the following apply to you? (please check yes or no for ALL the following) Page 4 Symptom Yes No Problem with bleeding Problem with healing Problem with scarring (hypertrophic, keloid) Immunosuppression Changing mole Rash Abdominal pain Anxiety Bloody stool Bloody urine Blurry vision Chest pain Cough Depression Fever or chills Headaches Hay fever Joint aches Muscle weakness Seizures Shortness of breath Sore throat Thyroid problems Unintentional weight loss Wheezing WOMEN periods irregular Other Symptoms:

Alerts: Do any of the following apply to you? (please check yes or no for ALL the following) Page 5 Alert Yes No Pacemaker Defibrillator Artificial joints within past 2 years Artificial heart valve Premedication required prior to procedures Allergy to adhesives Allergy to topical antibiotic ointments Allergy to latex Allergy to lidocaine (pain killer) Rapid heart beat with epinephrine (in pain killer) Taking blood thinners GI upset with antibiotics WOMEN - Pregnancy or Planning a pregnancy WOMEN - Yeast infections with antibiotics Other Symptoms:

Page 6 (The following information is required by Medicare for ALL patients for Meaningful Use of electronic medical records. If you have any questions as to why, please contact Medicare.) PREFERRED LANGUAGE RACE (please circle one) - WHITE - AMERICAN INDIAN OR NATIVE ALASKAN - ASIAN - BLACK OR AFRICAN-AMERICAN - NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER - OTHER RACE ETHNIC GROUP (please circle one) - HISPANIC OR LATINO - NOT HISPANIC OR LATINO - UNKNOWN ----------------------------------------------------------- PHARMACY INFORMATION LOCAL PHARMACY - NAME STREET CITY MAIL ORDER PHARMACY- NAME CITY

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