2025 Updated 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
Address:
Apt/Unit:
City:
State:
Zip:
Preferred Telephone #:
Type:

Other
Alternate Telephone #:
Type:

Other
Is it OK to leave a detailed message?
If yes, which phone:
Email Address:
example@example.com
Preferred Contact Method
Language (please choose all that apply)

Other
Race

Other
Ethnicity
Employment:
Employer:
Occupation:
Industry:
Retired:
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?
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.

Other
PAST SURGICAL HISTORY. Check all that apply.

Other
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.

Other
Do you wear sunscreen
If yes, indicate the SPF used:
Do you tan in a tanning salon?
Family History:
Does anyone in your family have:
Which relative(s) has melanoma?
Which relative(s) has skin cancer?
Which relative(s) has other disease?
Medications:

Rows	Name	Dosage	Route	Frequency
1
2
3
4
5
6
7
8
9

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

Other
Alcohol Use:
Male: How many times in the last year did you have 5 or more drinks in a day?
blanks
Female: How many times in the last year did you have 4 or more drinks in a day?
blanks
Smoking history:
Do you smoke?
If you are a current or former smoker, how many packs per day? Put 0 if nonsmoker.
Do you have any of the following? Check all that apply.
Do any of the following apply to you? Check all that apply.
Required Questions:
1. Would you allow a medical student and/or resident physician to observe during your visit?
Are you 65 years old or older?
2. Have you received the flu immunization in the last year?
If not, why?
3. Have you ever received a pneumonia vaccine?
If not, why?
4. Do you have a surrogate decision maker?
Surrogate Decision Maker's Name
Surrogate's Phone Number
Immunizations Fora Adolescents: Received one dose of meningococcal vaccine, one Tdap, and at least 2 - 3 HPV vaccines by their 13th birthday?
Thank you for your time and patience!
Should be Empty: