www.drvitulli.com - History and Intake Form

History and Intake Form
Patient Name*

First NameLast Name
Birth of Date*

MonthDayYear
Age
Pharmacy Name
Pharmacy Address
Pharmacy Phone Number
Please enter a valid phone number.
Past Medical History - Select any of the following medical conditions you currently have (please, select all that apply)*

AnxietyArthritisAsthmaAtrial FibrillationBone Marrow TransplantBPHBreast CancerColon CancerCOPDHIV/AIDSHypercholesterolemiaCoronary Artery DiseaseDepressionDiabetesEnd-Stage Renal DiseaseGERDHearing LossHepatitisHypertensionHyperthyroidismLeukemiaLung CancerLymphomaProstate CancerRadiation treatmentSeizuresStrokeNONEOther
Past Surgical History-Have you had any surgeries on the following organs? (please, select all that apply) *

Appendix RemovedBladder RemovedBreast BiopsyBreast: MastectomyBreast: LumpectomyColectomy: Colon Cancer ResectionColectomy: DiverticulitisColectomy: Inflammatory Bowel DiseaseColon: ColostomyGallbladder RemovedHeart: Biological Valve ReplacementHeart: Coronary Artery BypassHeart: Heart TransplantHeart: Mechanical Valve ReplacementHeart: PTCAJoint Replacement, HipJoint Replacement, KneeKidney BiopsyKidney Stone RemovalKidney TransplantKidney: NephrectomyLiver: HepatectomyLiver: Liver TransplantLiver: ShuntOvaries Removed: EndometriosisOvaries Removed: Ovarian CancerOvaries Removed: Ovarian CystOvaries: Tubal LigationProstate: Pancreas: PancreatectomyProstate BiopsyProstate: Prostate CancerProstate: TURPRectum: APRRectum: Low Anterior ResectionSkin: Basal Cell CancerSkin: MelanomaSkin: Skin BiopsySkin: Squamous Cell CarcinomaSpleen RemovedTesticles RemovedUterus: Cervical CancerUterus: Hysterectomy-FibroidsUterus: Hysterectomy-Uterine CancerNONEOther
Breast Biopsy

RightLeftBilateral
Breast: Mastectomy

RightLeftBilateral
Breast: Lumpectomy

RightLeftBilateral
Joint Replacement, Hip

RightLeftBilateral
Joint Replacement, Knee

RightLeftBilateral
Testicles Removed

RightLeftBilateral
Skin Disease History-Have you had any of the following skin conditions? (please, select all that apply)

AcneActinic KeratosesAsthmaBasal Cell Skin CancerBlistering SunburnsDry SkinEczemaFlaking or Itchy ScalpHay Fever/AllergiesMelanomaPoison IvyPrecancerous MolesPsoriasisSquamous cell skin cancerNONEOther
Do you wear sunscreen?

YesNo
If yes, what SPF?
Do you tan in a tanning salon?

YesNo
Present Medications
List any medications you are taking at this time. Include such items as aspirin, vitamins, laxatives, etc.
Allergies (please, list ALL allergies.)
Social History (please, check all that apply)
Currently smokes – dailyCurrently smokes– not dailyHas Never smokedHas smoked in the pastDrug useNone
Started Smoking?
Quit Smoking?
Number of packs per day?
Total years Smoking?
Not sexually activeEtoH nonePatient feels safe at homeSexually active with one partnerEtoH less than 1 drink per dayPatient feels unsafe at homeSexually active with more than one partnerEtoH 1-2 drinks per dayIV drug useEtoH 3 or more drinks per dayOther
Driving status

Drives in the DaytimeDrives at Night
How often do you exercise?
What is your caffeine use?
Occupation and Workplace
Place of Residence
Review of Systems

Are you CURRENTLY experiencing any of the following? (please, check yes or no for the following)
Problems with bleeding*

YesNo
Problems with healing*

YesNo
Problems with scarring*

YesNo
Immunosuppression*

YesNo
Changing Mole*

YesNo
Rash*

YesNo
Abdominal pain*

YesNo
Anxiety*

YesNo
Bloody stool*

YesNo
Bloody urine*

YesNo
Blurry vision*

YesNo
Chest pain*

YesNo
Cough*

YesNo
Depression*

YesNo
Fever or chills*

YesNo
Headaches*

YesNo
Hay Fever*

YesNo
Joint aches*

YesNo
Muscle weakness*

YesNo
Neck stiffness*

YesNo
Night sweats*

YesNo
Seizures*

YesNo
Shortness of breath*

YesNo
Sore throat*

YesNo
Thyroid problems*

YesNo
Unintentional weight loss*

YesNo
Wheezing*

YesNo
Alerts (please, check any that you have experienced)
PacemakerBlood thinnersWest Africa: Travel or contactDefibrillatorPregnancy or planning a pregnancyEbola Risk: Fever > = 100.4 degreesArtificial joints within the past 2 yearsAllergy to lidocaineEbola Risk: Resided or Traveled toCountry-wide spread Ebola transmission in last 21 daysArtificial heart valveRapid Heart Beat with epinephrinePremedication prior to proceduresYeast infections with antibioticsAllergy to adhesiveGI upset with antibioticsAllergy to topical antibiotic ointmentsOther
Vaccinations and Advanced Directive

Please tell us when you were last vaccinated for the following
Flu (patients age 6 months and older)*

YesNo
Date

MonthDayYear
Pneumonia (patients age 65 and older)*

YesNo
Date

MonthDayYear
Advanced directive: a document called a living will advise your family and physicians of your decisions should you become incapacitated or unable to make choices of your own.
Have you prepared a living will?*

YesNo
First Degree Family History: (please check all that apply)
Melanoma

MotherFatherSisterBrotherDaughterSonN/A
Cancer

MotherFatherSisterBrotherDaughterSonN/A
Psoriasis

MotherFatherSisterBrotherDaughterSonN/A
Arthritis

MotherFatherSisterBrotherDaughterSonN/A
Diabetes

MotherFatherSisterBrotherDaughterSonN/A
Colitis

MotherFatherSisterBrotherDaughterSonN/A
Atrial Fibrillation

MotherFatherSisterBrotherDaughterSonN/A
Hypertension

MotherFatherSisterBrotherDaughterSonN/A
Heart Disease

MotherFatherSisterBrotherDaughterSonN/A
Bleeding Disorders

MotherFatherSisterBrotherDaughterSonN/A
Liver Disease

MotherFatherSisterBrotherDaughterSonN/A
Kidney Disease

MotherFatherSisterBrotherDaughterSonN/A
Genetic Disorders

MotherFatherSisterBrotherDaughterSonN/A
Seizure Disorder

MotherFatherSisterBrotherDaughterSonN/A
Stroke

MotherFatherSisterBrotherDaughterSonN/A
Anxiety

MotherFatherSisterBrotherDaughterSonN/A
Depression

MotherFatherSisterBrotherDaughterSonN/A
Smoking

MotherFatherSisterBrotherDaughterSonN/A
Alcoholism

MotherFatherSisterBrotherDaughterSonN/A
Drug Dependency

MotherFatherSisterBrotherDaughterSonN/A
Minor in - office treatments and procedures consent

Skin biopsies, treatments with liquid nitrogen (cryotherapy), and intralesional injections are some of the most commonly performed procedures during dermatological examinations.

Skin biopsy is a minor surgical procedure which involves the removal of a small piece of skin under local anesthesia to obtain diagnostic information.

Cryotherapy is used to treat/remove/destroy numerous benign, precancerous, and cancerous skin conditions. Some of these include warts, sunspots, actinic keratoses, and superficial skin cancers.

Intralesional (and intramuscular) steroid injections are often performed to decrease pain, swelling and inflammation.

These procedures/treatments may be associated with certain side effects and complications, which include, but are not limited to the following

BIOPSY	CRYOTHERAPY	INJECTION
Bleeding	Pain	Pain and hypersensitivity
Pain	Infection	Infection
Infection	Redness and erythema	Bruising
Change of pigmentation	Blister and scab formation	Abscess
Nerve damage	Discoloration	Discoloration
Recurrence of growth	Nerve damage	Skin atrophy
Altered skin sensation	Altered skin sensation
Scarring	Scarring

Multiple treatments/procedures may be needed to achieve an optimal resolution of concerning issues.

Feel free to ask your provider any questions regarding the above procedures and their complications.
Authorization for treatment
I certify that I have read and fully understand the information contained in this document. I accept the risks and complications of the described procedures, and hereby authorize the physicians and clinical staff of the Practice to administer these treatments/procedures as deemed necessary. I will not hold Dr. Vitulli, his associates and staff members of the Practice liable for any adverse side effects associated with these procedures.
Patient’s Name *

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Patient/Responsible Party Signature *

Clear
Date*

MonthDayYear

History and Intake Form

Present Medications

Social History (please, check all that apply)

Review of Systems

Alerts (please, check any that you have experienced)

Vaccinations and Advanced Directive

First Degree Family History: (please check all that apply)

Minor in - office treatments and procedures consent

Authorization for treatment

Cosmetic questionnaire

Areas of concern

Would you like information on any of the following procedures?