Essential Dermatology, PLLC
New Patient Medical History Form
Name
*
First Name
Middle Name
Last Name
Suffix
Chosen name/Nickname
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Office communication email use
Decline
Other
Phone Number
*
-
Area Code
Phone Number
OK leave message
*
YES
NO
Gender identity
Pronouns
Sexual orientation
Marital Status
Single
Married
Divorced
Widowed
Separated
Other
Pharmacy Name
*
Pharmacy City
*
Primary Care Provider Name
*
Emergency Contact/Parent/Guardian/Next of Kin Information:
Name
*
Phone Number
*
-
Area Code
Phone Number
Relationship
*
May we discuss appointments and health information with this person
*
Yes
No
What is the primary reason for the visit
*
Allergies:
List allergies to food and/or medications. Write in NONE if appropriate.
*
Current Medications:
List current medication(s), dose, & frequency. Write NONE if appropriate.
*
Past History:
Have you had skin cancer
*
YES
NO
If YES above, was it MELANOMA
YES
NO
Do you have a family history of skin cancer
*
YES
NO
If YES above, do you have a family history of MELANOMA
YES
NO
Do you have a history of bleeding disorder
*
YES
NO
Do you have a pacemaker
*
YES
NO
Do you take a blood thinner
*
YES
NO
Do you have a history of tanning bed use
*
YES
NO
Do you have a history of radiation therapy
*
YES
NO
Do you have a history of PUVA treatment
*
YES
NO
Do you have a history of organ transplantation
*
YES
NO
Do you have a history of immunosuppressive therapy
*
YES
NO
Do you have replaced joints and/or heart valve(s)
*
YES
NO
What major medical problems are you being monitored for on a regular basis:
Melanoma History:
Please answer ONLY if you have a history of MELANOMA
Is this being monitored by another clinician presently
YES
NO
Do you have a regularly scheduled follow-up appointment to monitor the melanoma
YES
NO
Has an imaging test (X-RAY, CT-SCAN, etc) been ordered for the melanoma
YES
NO
Social History:
Do you smoke
*
YES
NO
If you ARE a smoker, please select your current age
Age 21 y +
Younger than 21 y
WOMEN ONLY, are you pregnant
YES
NO
Review of Symptoms:
Please select YES if you have current or former problems with the following:
Eyes / Glaucoma / Cataracts
*
NO
YES
Ears / Nose / Throat / Mouth
*
NO
YES
Heart / Blood Pressure
*
NO
YES
Lungs / Asthma
*
NO
YES
Stomach / Gastrointestinal
*
NO
YES
Kidneys
*
NO
YES
Arthritis / Muscles / Joints
*
NO
YES
Headache / Stroke
*
NO
YES
Anxiety / Depression
*
NO
YES
Thyroid / Diabetes / Endocrine
*
NO
YES
Anemia / Bleeding
*
NO
YES
Hepatitis / HIV / Tuberculosis
*
NO
YES
If you answered YES to any of the questions above, please elaborate below
Insurance Card: Please upload photos of the FRONT and BACK of your insurance card(s)
Browse Files
If you are self-pay, please upload a photo ID
Cancel
of
I have reviewed all information on this form. Patient / Guardian Signature:
*
Submit
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