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History and Intake Form NAME:____________________________________________ DATE OF BIRTH:_______________________ Primary Care Physician or Referring Physician: ______________________________________________________ Reason for visit: ____________________________________________________________________________________________ Medical History: (please circle all that apply) Anxiety Arthritis Hepatitis Artificial joints Hypertension Asthma HIV/AIDS Atrial fibrillation Hypercholesterolemia BPH (Benign Prostatic Hyperplasia) Hyperthyroidism Bone Marrow Transplantation Hypothyroidism Breast Cancer Leukemia Colon Cancer Lung Cancer COPD (Emphysema) Lymphoma Coronary Artery Disease Pacemaker Dementia Prostate Cancer Depression Radiation Treatment Diabetes Seizures End Stage Renal Disease Stroke GERD (Acid reflux) Valve Replacement Hearing Loss None Other _________________________________________________________________________________________ Surgical History: (please circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Kidney Removed (Right, Left) Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Page 1 of 3 Surgical History: (cont’d.) Prostate Removed: Prostate Cancer Melanoma Surgery Prostate Biopsy Spleen Removed TURP Testicles Removed (Right, Left, Bilateral) Skin Biopsy Hysterectomy: Fibroids Basal Cell Cancer Surgery Hysterectomy: Uterine Cancer Squamous Cell Carcinoma Surgery None Other _________________________________________________________________________________________ Skin Disease History: (please circle all that apply) Acne Hay Fever/Allergies Actinic Keratoses Melanoma Asthma Poison Ivy Basal Cell Skin Cancer Precancerous Moles Blistering Sunburns Psoriasis Dry Skin Squamous Cell Skin Cancer Eczema None Flaking or Itchy Scalp Other ________________________________________________________________________________________ Do you wear Sunscreen? Yes No If yes, what SPF? ___________ Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If yes, which relative(s)? ___________________________________________________________________ Family Health History: (parents, siblings, or children) Please indicate which relative & type of disease Any skin cancer (other than melanoma)? _____________________________ Any skin disease? __________________________________________ Any other cancer? Diabetes? Medications: (Please enter all current medications, including dose and frequency) ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Page 2 of 3 Medication Allergies: (Please enter all medication allergies) Social History: (please circle one) Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily Language: English Spanish Other:__________________ Ethnicity: Hispanic/Latino Non-Hispanic/Latino How often do you exercise? Once a day A few times a week A few times a month Never Alcohol Use: YES Less than 1 drink/day 1-2 drinks/day 3 or more drinks/day NO Race: White Black/African American Asian American Indian or Native Alaskan Native Hawaiian/Pacific Islander What is your caffeine use? Once a day A few times a week A few times a month Never Pharmacy: Name:___________________________________________________________________________________ Street:_______________________________________________ Zipcode:_________________________ Signature of Patient or Legal Representative Date Page 3 of 3
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