Fora Dermatology New Patient Intake

New Patient Intake

Welcome to Fora Dermatology! Please fill out all fields of the form
Personal Information:
Name*

First NameLast Name
Date:*

MonthDayYear
Date
Martial Status*
SSN:*
Date of Birth:*

MonthDayYear
Date
Gender*

MaleFemale
Address:*
Apt/Unit:
City:*
State:*
Zip:*
Preferred Telephone #:*
Type:*

HomeCellWorkOther
Alternate Telephone #:
Type:

HomeCellWorkOther
Is it OK to leave a detailed message?*

YESNO
If yes, which phone:*

PreferredAlternativeOther
Email Address:*
example@example.com
Preferred Contact Method*

PhoneEmailPortalLetterFax
Language (please choose all that apply)*

EnglishSpanishDeclineOther
Race*

American Indian or Native AlaskanAsianBlack or African AmericanMiddle EasternNative Hawaiian or Pacific IslanderWhiteDeclineOther
Ethnicity*

Hispanic or LatinoNot Hispanic or LatinoDecline
Employment:
Employer:*
Occupation:*
Industry:
Retired:*

YESNO
Emergency Contact and Authorization to share Medical Information:
Name*

First NameLast Name
Relationship*
Phone*
Do we have permission to share medical results and information with the above person?*

YES .NO
Any additional authorized person:
Name:
Relationship:
Phone:
Primary and Referring Doctors:
Primary Care Doctor:*
Referring Doctor:*
Preferred Pharmacy:
Name:*
City/Street OR street intersection:*
Phone :*
Height and Weight:
Height:*
Weight:*
Past Medical and Surgical History:
PAST MEDICAL HISTORY. Check all that apply.*

AnxietyArthritisAsthmaAtrial FibrillationBone Marrow TransplantBenign Prostate Hyperplasia (BPH)Breast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesEnd Stage Renal DiseaseGERDHearing lossHepatitisHypertensionHIV/AIDSHypercholesterolemiaHyPERthyroidismHyPOthyroidismLeukemiaLung CancerLymphomaProstate CancerRadiation TreatmentSeizuresStrokeNoneOther
PAST SURGICAL HISTORY. Check all that apply.*

Appendix removalBladder removalBreast biopsyLumpectomy- rightLumpectomy- leftLumpectomy- bothMastectomy- rightMastectomy- leftMastectomy- bothColon Cancer- colon removalDiverticulitis- colon removalInflammatory Bowel Disease- colon removalColostomyGallbladder removedBiological heart valve replacedCoronary Artery Bypass Surgery (CABG)Heart transplantMechanical heart valve replacedHeart catheterization, no stentsHeart cath WITH stents (note number below)Right hip replacedLeft hip replacedBoth hips replacedRight knee replacedLeft knee replacedBoth knees replacedKidney biopsyKidney STONE removalKidney transplantKidney removalLiver removalLiver transplantLiver shuntEndometriosis- ovaries removedOvarian cyst- ovaries removedTubal ligation (note below if ovaries removed)Ovarian cancer removalPancreas removedProstate biopsyProstate cancer- prostate removedTURP (prostate removed through urethra)Abdominoperineal rectum removalLow anterior rectum removalSkin BiopsyBasal cell carcinomaSquamous cell carcinomaMelanomaSpleen removedTesticles removedUterine fibroids removalUterine cancer removalCervical cancer surgeryNoneOther
For each of the surgeries noted above, please indicate year if known. (Also note here: number of heart stents and if ovaries removed with tubal ligation.)
Have you had any of the following skin conditions? Check all that apply.*

AcneActinic keratosis (pre-cancer)AsthmaBasal cell cancerBlistering sunburnsDry skinEczemaFlaking or itchy scalpHay fever or allergiesMelanomaPoison ivyPrecancerous molesPsoriasisSquamous cell cancerNoneOther
Do you wear sunscreen*

NOYES
If yes, indicate the SPF used:
Do you tan in a tanning salon?*

NOYES
Family History:
Does anyone in your family have:*

MelanomaOther skin cancerOther diseases?None
Which relative(s) has melanoma?
Which relative(s) has skin cancer?
Which relative(s) has other disease?
Medications:
Please list the name/dosage/route/frequency or bring your medication list to your appointment

I will bring my medication list to my appointment

Medication Allergies/Reaction: Please indication allergies to medications AND your reaction.*

No Known Drug AllergiesOther
Alcohol Use:
How many times in the last year did you have 5 or more drinks in a day?*

0-1 day2+ days
How many times in the last year did you have 4 or more drinks in a day?*

0-1 day2+ days
Smoking history:
Do you smoke?*

NeverFormerCurrent
If you are a current or former smoker, how many packs per day? Put 0 if nonsmoker. *
For how many years did you smoke? Put 0 if nonsmoker.*
Do you have any of the following? Check all that apply.*

Problems with healingProblems with scarringRashHay FeverFever/chillsNight sweatsThyroid problemsChest painSore throatBlurry visionAbdominal painBloody stoolBloody urineJoint achesMuscle weaknessNeck StiffnessHeadachesSeizuresCoughShortness of breathWheezingAnxietyUnintentional weight lossDepressionNone
Do any of the following apply to you? Check all that apply.*

Allergy to latexDefibrillatorPacemakerBlood thinnerArtificial heart valveArtificial joints within the past 2 yearsPremedication prior to proceduresAllergy to adhesiveAllergy to lidocaineRapid heartbeat with epinephrineAllergy to topical antibiotic ointmentsMRSA infectionPregnancy or planning a pregnancyProblems with bleedingImmunosuppressionHistory of hepatitisHistory of HIVNone
Required Questions:
1. Would you allow a medical student and/or resident physician to observe during your visit?*

YESNO
Are you 65 years old or older?*

YESNO
2. Have you received the flu immunization in the last year?*

YESNO
If not, why?
3. Have you ever received a pneumonia vaccine?*

YESNO
If not, why?
4. Do you have a surrogate decision maker?*

NOYES
Surrogate Decision Maker's Name
Surrogate's Phone Number
Thank you for your time and patience!
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