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Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE: (914) 833-3030, FAX (914) 833-3034 PAST MEDICAL HISTORY PLEASE CIRCLE ALL THAT APPLY. Select any of the following medical conditions that you currently have or have had in the past: Anxiety Arthritis Asthma Atrial Fibrilation (Irregular Heartbeat) Bone Marrow Transplantation BPH (Enlarged Prostate) Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia (High Cholesterol) Hyperthyroidism Hypothyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation Treatment Seizures Stroke None Other PAST SURGERIES Have you had any surgeries on the following organs? Appendix (Appendectomy) Breast: Mastectomy (Right Breast) Breast: Mastectomy (Both Breasts) Breast: Lumpectomy (Left Breast) Breast: Breast Biopsy Breast: Breast Implants Colon (Colectomy): Diverticulitis Gallbladder (Cholecystectomy) Bladder (Cystectomy) Breast: Mastectomy (Left Breast) Breast: Lumpectomy (Right Breast) Breast: Lumpectomy (Both Breasts) Breast: Breast Reduction Colon (Colectomy): Colon Cancer Resection Colon (Colectomy): Inflammatory Bowel Disease Heart: Coronary Artery Bypass Surgery 1 P age

PAST SURGERIES (continued) Heart: PTCA Heart: Biological Valve Replacement Joint Replacement: Knee (Right) Joint Replacement: Knee (Both) Joint Replacement: Hip (Left) Kidney: Kidney Biopsy Kidney: Kidney Stone Removal Ovaries (Oophorectomy): Endometriosis Ovaries (Oophorectomy) Ovarian Cancer Prostate (Prostatectomy): Prostate Biopsy Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen (Splenectomy) Uterus (Hysterectomy): Fibroids Other Heart: Mechanical Valve Replacement Heart: Heart Transplant Joint Replacement: Knee (Left) Joint Replacement: Hip (Right) Joint Replacement: Hip (Both) Kidney: Nephrectomy Kidney: Kidney Transplant Ovaries (Oophorectomy): Ovarian Cyst Prostate (Prostatectomy): Prostate Cancer Prostate (Prostatectomy): TURP Skin: Basal Cell Carcinoma Skin: Melanoma Testicles (Orchiectomy) Uterus (Hysterectomy: Uterine Cancer None SKIN DISEASE HISTORY Have you had any of the following skin conditions? Acne Actinic Keratoses Asthma Basal Cell Skin Cancer Blistering Sunburns Dry Skin Eczema Flaking or Itchy Scalp Hay Fever/Allergies Melanoma 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 2 P age

Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE (914) 833-3030, FAX (914) 833-3034 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 MEDICATIONS Please enter all current medications (oral, injectable, patch): ALLERGIES/REACTIONS Please enter all allergies to medications and describe any associated reactions: SOCIAL HISTORY Alcohol (EtOH) Intake: None Less than 1 drink per day 1-2 drinks per day 3 or more drinks per day Smoking Status: Current every day smoker Current some day smoker Former smoker Never smoker Smoker current status unknown Unknown if ever smoked How often do you exercise? Several times a day Once a day A few times a week A few times a month Never 3 P age

What is your caffeine use? Several times a day Once a day A few times a week A few times a month Never Occupation and Workplace: Preferred Language: Race: White American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander Other Race Ethnic Group: Hispanic or Latino Not Hispanic or Latino Unknown Preferred phone number: home/cell/work (please specify) Is it Ok to leave a detailed message? YES/NO Preferred Pharmacy: Some Local Pharmacies: Name CVS Chatsworth Ave CVS (Wykagyl New Rochelle) Address CVS Ferndale (Near Stop & Shop) Rye Beach Pharmacy City CVS (Near Staples) Trotta s (Harrison) Phone CVS (Pelham Manor) Walgreens (Near Hommocks) Thank you for completing the above series of questions, many of which relate to the Electronic Health Records Mandate. 4 P age

Adult and Pediatric Dermatology Cosmetic Dermatology 3 NORTH AVENUE PHONE (914) 833-3030, FAX (914) 833-3034 REVIEW OF SYSTEMS PLEASE CIRCLE ALL THAT APPLY. Select any of the following body system complaints that you currently have: Problems with bleeding Problems with healing Rash Problems with scarring (hypertrophic or keloid) Immunosuppression Hay fever Chest Pain Fever or chills Night sweats Unintentional weight loss Thyroid problems Sore throat Blurry vision Abdominal pain Nausea Diarrhea Bloody stool Wheezing Anxiety Depression Allergy to adhesive Allergy to lidocaine Allergy to topical antibiotic ointments Artificial heart valve Artificial joints within past two years Blood thinners Defibrillator MRSA Pacemaker Premedication prior to procedures Rapid heart beat with epinephrine Pregnancy or planning a pregnancy, nursing History of melanoma Other Bloody urine Joint aches Muscle weakness Neck stiffness Headaches Seizures Cough Shortness of Breath 5 P age

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