San Luis Dermatology & Laser Clinic, Inc.

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San Luis Dermatology & Laser Clinic, Inc. Patient Name: Pharmacy Name: Primary Care physician: LOCATION City: Health History Intake Form The federal government has defined a complete electronic medical record (EMR) or electronic health record (EHR) as containing four basic functions: computerized orders for prescriptions, computerized orders for tests, reporting of test results, and physician notes. In 2009, as a part of the Economic Stimulus, the federal government began offering incentives to providers to encourage implementation of electronic health records. Providers must attest to demonstrating meaningful use every year to avoid payment adjustment. Providers have to show that they are meaningfully using their EHRs by meeting thresholds for a number of objectives. As part of the objectives we are asked to have our patients complete medical history questions, and demographics so that we may eventually qualify for meaningful use. Thank you for your cooperation in completing this information. Past Medical History: (please all that apply) Anxiety Arthritis Asthma Atrial fibrillation BPH Bone Marrow Transplantation Breast Cancer Colon Cancer COPD Coronary Artery Disease Depression Diabetes 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 Reviewed by: MPH RJH CBF JWD Date: Initials Page 1 of 5

Past Surgical History: (please all that apply) Appendix Removed(Appendectomy) Bladder Removed (Cystectomy) Mastectomy ( Right Left Both) Lumpectomy ( Right Left Both) Breast Biopsy( Right Left Both) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Percutaneous transluminal coronary angioplasty (ptca) Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement Knee ( Right Left Both) Joint Replacement Hip ( Right Left Both) Kidney Biopsy Kidney Removed (Nephrectomy) (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed (splenectomy) Testicles Removed (Right, Left, Both) Uterus (Hysterectomy): Fibroids Uterus (Hysterectomy): Uterine Cancer Other Skin Disease History: (please all that apply) 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 Other Do you wear Sunscreen? Yes No SPF: Do you tan in a tanning salon? Yes No Page 2 of 5

Family History: Do you have a family history of Skin Cancer? Basal Cell Carcinoma Yes No Squamous Cell Carcinoma Yes No Do you have a family history of Melanoma? Yes No Mother Father Sister Brother Daughter Son Uncle Aunt Nephew Niece Grandmother Grandfather Grandson Granddaughter Other Medications: (Please enter all current medications, or attach legible list) *Include Strength and dosage* Example - Aspirin 81mg tablets 1 daily Allergies to Medications: (Please enter all drug allergies & reactions (i.e. rash) Alergies: Alergies: Reactions Reactions ALERTS: (please Yes/No for the following) Alerts: Yes No 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 procedure Rapid heartbeat with epinephrine Pregnancy or planning a pregnancy History of blood transfusions Page 3 of 5

Social History: (please all that apply) Smoking Status: Never smoked Quit: former smoker Smokes less than daily Smokes daily Illicit Drug Use: Drug Use IV Drug Use Alcohol Use (ETOH) Safety: Birth Place: Alcohol: none Alcohol: less than 1 drink a day Alcohol 1-2 drinks a day Alcohol: 3 or more drinks a day I feel safe at home. I do not feel safe at home. City State Country Other Quality Measures For patients 65 and older: Vaccination Status: Have you received a pneumonia vaccination? Yes No Advance Care Do you have a health care proxy in the event you are unable to make your own medical decisions? Yes No Do you have a living will: Yes No Page 4 of 5

Review of Systems: Are you currently experiencing any of the following? (Please Yes/No for the following) Symptom Yes No Problem with bleeding Problems with healing Problems with scarring(hypertrophic or keloid) Rash Immunosuppression Hay fever Chest pain Fever or chills Night sweats Unintentional weight loss Thyroid problems Sore throat Blurry vision Abdominal pain Bloody stool Bloody urine Joint aches Muscle Weakness Neck stiffness Headaches Seizures Cough Shortness of breath Wheezing Anxiety Depression Other Symptoms: My Primary Care Physician is aware of my current Alerts & Symptoms Yes No PATIENT SIGNATURE Date: Thank you! Page 5 of 5

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