www.drvitulli.com - History and Intake Form

  • History and Intake Form

  • Format: (000) 000-0000.
  • Past Medical History - Select any of the following medical conditions you currently have (please, select all that apply)*
  • Past Surgical History-Have you had any surgeries on the following organs? (please, select all that apply) *
  • Breast Biopsy
  • Breast: Mastectomy
  • Breast: Lumpectomy
  • Joint Replacement, Hip
  • Joint Replacement, Knee
  • Testicles Removed
  • Skin Disease History-Have you had any of the following skin conditions? (please, select all that apply)
  • Do you wear sunscreen?
  • Do you tan in a tanning salon?

  • Present Medications

  • Social History (please, check all that apply)

  • Driving status

  • Review of Systems

    Are you CURRENTLY experiencing any of the following? (please, check yes or no for the following)
  • Problems with bleeding*
  • Problems with healing*
  • Problems with scarring*
  • 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*
  • Neck stiffness*
  • Night sweats*
  • Seizures*
  • Shortness of breath*
  • Sore throat*
  • Thyroid problems*
  • Unintentional weight loss*
  • Wheezing*

  • Alerts (please, check any that you have experienced)

  • Vaccinations and Advanced Directive

    Please tell us when you were last vaccinated for the following
  • Flu (patients age 6 months and older)*
  • Date
     - -
  • Pneumonia (patients age 65 and older)*
  • Date
     - -

  • 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?*

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

  • Melanoma
  • Cancer
  • Psoriasis
  • Arthritis
  • Diabetes
  • Colitis
  • Atrial Fibrillation
  • Hypertension
  • Heart Disease
  • Bleeding Disorders
  • Liver Disease
  • Kidney Disease
  • Genetic Disorders
  • Seizure Disorder
  • Stroke
  • Anxiety
  • Depression
  • Smoking
  • Alcoholism
  • Drug Dependency

  • 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 Date of Birth*
     - -
  • Date*
     - -

  • Cosmetic questionnaire

  • Date*
     - -

  • Areas of concern

    (please, select all that apply)

  • Would you like information on any of the following procedures?

    (please, select all that apply)
  • Patient’s Date of Birth*
     - -
  • Date*
     - -
  • Should be Empty: