Pittsburgh Skin: History & Intake Form

History & Intake Form

Please fill-out and complete the form below, thank you.
PATIENT INFORMATION
Today's Date:*

MonthDayYear
Date
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Sex:*
Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address:*
example@example.com
Permission to Email?*

YesNo
Occupation:
Primary Care Doctor:
How did you hear about our office?
PAST MEDICAL HISTORY
Past Medical History (Please select all that apply):*

AnxietyArthritisAsthmaAtrial FibrilationBone MarrowTransplantationBreast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesEnd Stage Renal DiseasGERDHearing LossHepatitisHigh Blood PressureHIV/AIDSHigh CholesterolLeukemiaLung CancerLymphomaProstate CancerRadiation TreatmentSeizuresStrokeHypothyroidismHyperthyroidismNONE
Other Past Medical History (not listed):
PAST SURGICAL HISTORY
Past Surgical History (Please select all that apply):*

Appendix RemovedBiological Valve ReplacementBladder RemovedBreast ReductionBreast ImplantsColectomyCoronary Artery BypassGallbladder RemovedHeart TransplantHysterectomyJoint Replacement, KneeJoint Replacement, HipKidney Biopsy (Nephrectomy)Kidney RemovedKidney Stone RemovalKidney TransplantLumpectomyMastectomyMechanical Valve ReplacementOvaries RemovedProstate Removed: Prostate CancerTURP (Prostate Removal)Spleen RemovedTesticles RemovedNONE
Other Past Surgical History (not listed):
If "Colectomy" was selected, please provide reason:
If "Hysterectomy" was selected, please provide reason:
If "Knee Replacement" was selected, please indicate location:

RightLeftBilateral
Date of Knee Replacement

MonthDayYear
Date
If "Hip Replacement" was selected, please indicate location:

RightLeftBilateral
Date of Hip Replacement

MonthDayYear
Date
If "Kidney Removed" was selected, please indicate location:

RightLeft
If "Lumpectomy" was selected, please indicate location:

RightLeftBilateral
If "Masectomy" was selected, please indicate location

RightLeftBilateral
If "Ovaries Removed" was selected, please provide reason:
If "Testicles Removed " was selected, please indicate location:

RightLeftBilateral
SKIN DISEASE HISTORY
Skin Disease History (Please select all that apply):*

AcneActinic KeratosesAsthmaBasal Cell Skin CancerBlistering SunburnsDry SkinEczemaFlaky or Itchy ScalpHay Fever / AllergiesMelanomaMRSAPrecancerous MolesPoison IvyPrecancerous MolesPsoriasisSquamous Cell Skin CancerWartsNONE
Other Skin Disease History (not listed):
Do you wear sunscreen?*

YesNo
If yes, what SPF?
Do you tan at tanning salon?*

YesNo
Do you have a family history of melanoma?*

YesNo
If yes, which relatives?
MEDICATIONS
Medications (Please list all current medications, including dosage and frequency):
ALLERGIES
Allergies (Please list all allergies):
Health Care Proxy / Living Will
Do you have a Health Care Proxy?

YesNo
Do you have a Living Will?

YesNo
SOCIAL HISTORY
Social History - Cigarette Smoking:

Current SmokerFormer SmokerNever SmokedCigar Smoker
Social History - Do you drink alcohol?

YesNo
How many times in the past year have you had 5 or more drinks in a day?
Any other social history information you would like to share with us?
FAMILY MEDICAL HISTORY
Family Medical History (first degree relatives only):
LANGUAGE/RACE/ETHNICITY
Preferred Language:
Race:
Ethnic Group:
PHARMACY
Preferred Pharmacy Name:
Preferred Pharmacy Phone Number:
Preferred Pharmacy City or Zip Code:
INSURANCE
Insurance Policy Holder Name:
Insurance Policy Holder Date of Birth:

MonthDayYear
Date
Insurance Policy Holder Address (if not the same as your home address):
REVIEW OF SYMPTOMS
Are you currently experiencing any of the following? (Please select all that apply)

Problems with bleedingProblems with scarring (keloids)Problems with healingRashImmunosuppressionHay feverChest painFever or chillsUnintentional weight lossThyroid problemsSore throatBlurry visionAbdominal painHeadachesJoint AchesBloody stoolBloody urine
Any other symptoms you would like to share with us?
ALERTS
Please advise us of any alerts (Please check all that apply):

Allergy to adhesivesAllergy to lidocaineAllergy to topical antibioticsArtificial heart valveArtificial joint replacementBetadine/iodine allergyBlood thinnersDefibrillatorLatex allergyMRSAPacemakerRequire antibiotics prior to a surgical procedureRapid heart beat with epinehprine
Are you pregnant or trying to become pregnant?

YesNo
SIGNATURE
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

History & Intake Form

PATIENT INFORMATION

PAST MEDICAL HISTORY

PAST SURGICAL HISTORY

SKIN DISEASE HISTORY

MEDICATIONS

ALLERGIES

Health Care Proxy / Living Will

SOCIAL HISTORY

FAMILY MEDICAL HISTORY

LANGUAGE/RACE/ETHNICITY

PHARMACY

INSURANCE

REVIEW OF SYMPTOMS

ALERTS

SIGNATURE