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Download DermClinic_IntakeForm - Derm Clinic Peterborough
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Dr. C.L. Freeman MD, CCFP, Dip.Derm, MSc Family Medicine, practising in dermatology Date __________________________ Name _________________________________________ Birth date (month/day/year)________________________ Address_________________________________________________________________________________________ City___________________________________________________Postal Code ______________________ Phone (Home) __________________________________ (Work) _________________________________________ (Can we contact you at this number?_________) Other contacts (email, fax, cell phone, alt number we can leave a message) ________________________________________ Family Doctor ______________________________ Referring Doctor__________________________ Reason for your office visit today: ______________________________________Are you or could you be pregnant? ________ Have you seen Drs. Freeman/Gooderham/Singh ( please circle) in the past? _______________ When?___________________ Reason for past appointment? ______________________________________________________________________________ Please list any known SKIN conditions: (past and present) INCLUDING CANCERS OR MELANOMAS(s): Medications/ creams tried for your current skin problem ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ALL medications you currently use for any medical condition Please list all medical conditions:(past and present) ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ________________________ If providing a list please give to reception ____________________________ ____________________________ ____________________________ ____________________________ __________________________ Are you on a blood thinner? (Aspirin, Plavix, Coumadin, other): Yes No Please list any allergies to medications: _________________________________________________________________ What pharmacy do you use? ________________________________Location of pharmacy?_______________________ Family History (please circle any conditions present in bloodline family members and indicate who that person is): Melanoma Non-melanoma skin cancer Psoriasis Autoimmune Disorders Other Cancer Diabetes I have read and understand ‘Office Policies’ for Dermatology: Thyroid Disease Stroke Bowel Disease Arthritis Blood Clots Eczema ______________________________________________ (Please sign)
