www.drvitulli.com - History and Intake Form

History and Intake Form
Patient Name *

First Name Last Name
Birth of Date *

Month Day Year
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) *

Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplant BPH Breast Cancer Colon Cancer COPD HIV/AIDS Hypercholesterolemia Coronary Artery Disease Depression Diabetes End-Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension Hyperthyroidism Leukemia Lung Cancer Lymphoma Prostate Cancer Radiation treatment Seizures Stroke NONE Other
Past Surgical History-Have you had any surgeries on the following organs? (please, select all that apply) *

Appendix Removed Bladder Removed Breast Biopsy Breast: Mastectomy Breast: Lumpectomy Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: Inflammatory Bowel Disease Colon: Colostomy Gallbladder Removed Heart: Biological Valve Replacement Heart: Coronary Artery Bypass Heart: Heart Transplant Heart: Mechanical Valve Replacement Heart: PTCA Joint Replacement, Hip Joint Replacement, Knee Kidney Biopsy Kidney Stone Removal Kidney Transplant Kidney: Nephrectomy Liver: Hepatectomy Liver: Liver Transplant Liver: Shunt Ovaries Removed: Endometriosis Ovaries Removed: Ovarian Cancer Ovaries Removed: Ovarian Cyst Ovaries: Tubal Ligation Prostate: Pancreas: Pancreatectomy Prostate Biopsy Prostate: Prostate Cancer Prostate: TURP Rectum: APR Rectum: Low Anterior Resection Skin: Basal Cell Cancer Skin: Melanoma Skin: Skin Biopsy Skin: Squamous Cell Carcinoma Spleen Removed Testicles Removed Uterus: Cervical Cancer Uterus: Hysterectomy-Fibroids Uterus: Hysterectomy-Uterine Cancer NONE Other
Breast Biopsy

Right Left Bilateral
Breast: Mastectomy

Right Left Bilateral
Breast: Lumpectomy

Right Left Bilateral
Joint Replacement, Hip

Right Left Bilateral
Joint Replacement, Knee

Right Left Bilateral
Testicles Removed

Right Left Bilateral
Skin Disease History-Have you had any of the following skin conditions? (please, select 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 NONE Other
Do you wear sunscreen?

Yes No
If yes, what SPF?
Do you tan in a tanning salon?

Yes No
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 – daily Currently smokes– not daily Has Never smoked Has smoked in the past Drug use None
Started Smoking?
Quit Smoking?
Number of packs per day?
Total years Smoking?
Not sexually active EtoH none Patient feels safe at home Sexually active with one partner EtoH less than 1 drink per day Patient feels unsafe at home Sexually active with more than one partner EtoH 1-2 drinks per day IV drug use EtoH 3 or more drinks per day Other
Driving status

Drives in the Daytime Drives 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 *

Yes No
Problems with healing *

Yes No
Problems with scarring *

Yes No
Immunosuppression *

Yes No
Changing Mole *

Yes No
Rash *

Yes No
Abdominal pain *

Yes No
Anxiety *

Yes No
Bloody stool *

Yes No
Bloody urine *

Yes No
Blurry vision *

Yes No
Chest pain *

Yes No
Cough *

Yes No
Depression *

Yes No
Fever or chills *

Yes No
Headaches *

Yes No
Hay Fever *

Yes No
Joint aches *

Yes No
Muscle weakness *

Yes No
Neck stiffness *

Yes No
Night sweats *

Yes No
Seizures *

Yes No
Shortness of breath *

Yes No
Sore throat *

Yes No
Thyroid problems *

Yes No
Unintentional weight loss *

Yes No
Wheezing *

Yes No
Alerts (please, check any that you have experienced)
Pacemaker Blood thinners West Africa: Travel or contact Defibrillator Pregnancy or planning a pregnancy Ebola Risk: Fever > = 100.4 degrees Artificial joints within the past 2 years Allergy to lidocaine Ebola Risk: Resided or Traveled to Country-wide spread Ebola transmission in last 21 days Artificial heart valve Rapid Heart Beat with epinephrine Premedication prior to procedures Yeast infections with antibiotics Allergy to adhesive GI upset with antibiotics Allergy to topical antibiotic ointments Other
Vaccinations and Advanced Directive

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

Yes No
Date

Month Day Year
Pneumonia (patients age 65 and older) *

Yes No
Date

Month Day Year
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? *

Yes No
First Degree Family History: (please check all that apply)
Melanoma

Mother Father Sister Brother Daughter Son N/A
Cancer

Mother Father Sister Brother Daughter Son N/A
Psoriasis

Mother Father Sister Brother Daughter Son N/A
Arthritis

Mother Father Sister Brother Daughter Son N/A
Diabetes

Mother Father Sister Brother Daughter Son N/A
Colitis

Mother Father Sister Brother Daughter Son N/A
Atrial Fibrillation

Mother Father Sister Brother Daughter Son N/A
Hypertension

Mother Father Sister Brother Daughter Son N/A
Heart Disease

Mother Father Sister Brother Daughter Son N/A
Bleeding Disorders

Mother Father Sister Brother Daughter Son N/A
Liver Disease

Mother Father Sister Brother Daughter Son N/A
Kidney Disease

Mother Father Sister Brother Daughter Son N/A
Genetic Disorders

Mother Father Sister Brother Daughter Son N/A
Seizure Disorder

Mother Father Sister Brother Daughter Son N/A
Stroke

Mother Father Sister Brother Daughter Son N/A
Anxiety

Mother Father Sister Brother Daughter Son N/A
Depression

Mother Father Sister Brother Daughter Son N/A
Smoking

Mother Father Sister Brother Daughter Son N/A
Alcoholism

Mother Father Sister Brother Daughter Son N/A
Drug Dependency

Mother Father Sister Brother Daughter Son N/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 Name Last Name
Patient’s Date of Birth *

Month Day Year
Patient/Responsible Party Signature *

Clear
Date *

Month Day Year

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?