Download Sandra Read, MD, Dermatology NEW PATIENT

 Sandra Read, MD, Dermatology NEW PATIENT ‐ Please fill out the top ½. Thank You Name_________________________________________________ DATE________________ Email address: If you would like to receive discount coupons, health information, updates:_____________________________________________________________________ Problem ‐ Rash, growth, wart, acne, itch, history skin cancer, etc_____________________________ How long have you had this problem? ______________Have you had treatment for this?________ Previous treatments_________________________________________________________________ Do you have allergies? Please list____________________________________________________ What medicine(s) are you currently taking?_________________________________________________ Family history for skin disease (psoriasis, skin cancer, eczema, etc)____________________________ For Women, are you pregnant, planning a pregnancy, using contraception, nursing?_____________ Would you like a total body skin exam today? Please inform the staff if you wish to have this service Please draw where your problem(s) are today Chief Complaint_________________________________________ PE__________________________________________________________________________ Diagnosis: 1._____________________________ __Treatment_________________________________________ _________________________________________ 2. _______________________________Treatment_____________________________________ _____ ___________________________________________ X: Discussed: ABCDE , Education Sun‐Smart/Wise sun protection, skin care, skin surgery, benefit/risks/alternative treatments, all questions answered, signs of infection, wound care instruction Return/Call Office:___________________________________________