History & Intake Form
Please fill-out and complete the form below, thank you.
PATIENT INFORMATION
Today's Date:
*
/
Month
/
Day
Year
Date
Name:
*
First Name
Last Name
Date of Birth:
*
/
Month
/
Day
Year
Date
Sex:
*
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address:
*
example@example.com
Permission to Email?
*
Yes
No
Occupation:
Primary Care Doctor:
How did you hear about our office?
PAST MEDICAL HISTORY
Past Medical History (Please select all that apply):
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Anxiety
Arthritis
Asthma
Atrial Fibrilation
Bone Marrow
Transplantation
Breast Cancer
Colon Cancer
COPD
Coronary Artery Disease
Depression
Diabetes
End Stage Renal Diseas
GERD
Hearing Loss
Hepatitis
High Blood Pressure
HIV/AIDS
High Cholesterol
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Radiation Treatment
Seizures
Stroke
Hypothyroidism
Hyperthyroidism
NONE
Other Past Medical History (not listed):
PAST SURGICAL HISTORY
Past Surgical History (Please select all that apply):
*
Appendix Removed
Biological Valve Replacement
Bladder Removed
Breast Reduction
Breast Implants
Colectomy
Coronary Artery Bypass
Gallbladder Removed
Heart Transplant
Hysterectomy
Joint Replacement, Knee
Joint Replacement, Hip
Kidney Biopsy (Nephrectomy)
Kidney Removed
Kidney Stone Removal
Kidney Transplant
Lumpectomy
Mastectomy
Mechanical Valve Replacement
Ovaries Removed
Prostate Removed: Prostate Cancer
TURP (Prostate Removal)
Spleen Removed
Testicles Removed
NONE
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:
Right
Left
Bilateral
Date of Knee Replacement
/
Month
/
Day
Year
Date
If "Hip Replacement" was selected, please indicate location:
Right
Left
Bilateral
Date of Hip Replacement
/
Month
/
Day
Year
Date
If "Kidney Removed" was selected, please indicate location:
Right
Left
If "Lumpectomy" was selected, please indicate location:
Right
Left
Bilateral
If "Masectomy" was selected, please indicate location
Right
Left
Bilateral
If "Ovaries Removed" was selected, please provide reason:
If "Testicles Removed " was selected, please indicate location:
Right
Left
Bilateral
SKIN DISEASE HISTORY
Skin Disease History (Please select all that apply):
*
Acne
Actinic Keratoses
Asthma
Basal Cell Skin Cancer
Blistering Sunburns
Dry Skin
Eczema
Flaky or Itchy Scalp
Hay Fever / Allergies
Melanoma
MRSA
Precancerous Moles
Poison Ivy
Precancerous Moles
Psoriasis
Squamous Cell Skin Cancer
Warts
NONE
Other Skin Disease History (not listed):
Do you wear sunscreen?
*
Yes
No
If yes, what SPF?
Do you tan at tanning salon?
*
Yes
No
Do you have a family history of melanoma?
*
Yes
No
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?
Yes
No
Do you have a Living Will?
Yes
No
SOCIAL HISTORY
Social History - Cigarette Smoking:
Current Smoker
Former Smoker
Never Smoked
Cigar Smoker
Social History - Do you drink alcohol?
Yes
No
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:
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Month
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Day
Year
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 bleeding
Problems with scarring (keloids)
Problems with healing
Rash
Immunosuppression
Hay fever
Chest pain
Fever or chills
Unintentional weight loss
Thyroid problems
Sore throat
Blurry vision
Abdominal pain
Headaches
Joint Aches
Bloody stool
Bloody 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 adhesives
Allergy to lidocaine
Allergy to topical antibiotics
Artificial heart valve
Artificial joint replacement
Betadine/iodine allergy
Blood thinners
Defibrillator
Latex allergy
MRSA
Pacemaker
Require antibiotics prior to a surgical procedure
Rapid heart beat with epinehprine
Are you pregnant or trying to become pregnant?
Yes
No
SIGNATURE
Signature
*
Date
*
/
Month
/
Day
Year
Date
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