ALLEN DERMATOLOGY & SKIN CANCER CENTER
Name: _____________________________ Date of Birth: ______________
(Circle Each that Apply)
Radiation Treatment
Skin Disease History
Seizures
Acne
Stroke
Actinic Keratosis
Other
Asthma
Asthma
Past Surgical History:
Appendix (Appendectomy)
Basal Cell Skin Cancer
Atrial Fibrillation
(Irregular Heart Beat)
Bladder (Cystectomy)
Dry Skin
BPH (Benign Prostatic
Hypertrophy)
Breast
Eczema
Colon
Flaking or Itchy Scalp
Bone Marrow
Transplantation
Gallbladder
Hay Fever / Allergies
Heart
Any Organ Transplantation
Joint Replacement
Herpes Simplex (Fever
Blister)
Breast Cancer
Kidney
Herpes Zoster (Shingles)
Colon Cancer
Ovaries
Melanoma
COPD
Prostate
Poison Ivy
Coronary Artery Disease
Skin
Precancerous Moles
Depression
Spleen
Psoriasis
Diabetes
Testicles
Squamous Cell Carcinoma
Renal Disease
Uterus
Do you wear sunscreen?
GERD (Gastro-esophageal
Reflux)
Other
Yes / No
Medical conditions that
you currently have:
Anxiety
Arthritis
Hearing Loss
Hepatitis
Hypertension
HIV/AIDS
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Leukemia
Lung Cancer
Lymphoma
Prostate Cancer
Social History:
Do you smoke?
Yes / No
Do you drink alcohol?
Yes / No
Married? Single? Other?
Do you have children?
Yes / No
Do you have pets?
Yes / No
Occupation:
____________
Blistering Sunburns
If yes, what SPF
_______
Do you tan in the tanning
salon? Yes / No
Do you have a family
history of melanoma?
Yes / No
If yes, which relative?
________________
Do you have a family
history of non-melanoma
skin cancer?
Yes / No
ALLEN DERMATOLOGY & SKIN CANCER CENTER
Name: _____________________________ Date of Birth: ______________
IMPORTANT INFORMATION:
List medications that you currently take:
(Circle each one that applies)
(Including over the counter medications,
hormones and vitamins)
Allergy to adhesive
Allergy to lidocaine
____________________________________
Allergy to topical antibiotic ointments
____________________________________
Artificial heart valve
____________________________________
Artificial joints within past two years
____________________________________
Blood thinners
____________________________________
Defibrillator
____________________________________
MRSA
____________________________________
Pacemaker
____________________________________
Premedication prior to procedures
____________________________________
Rapid heart beat with epinephrine
Pregnancy or planning a pregnancy
List allergies – medications, environmental
and food
____________________________________
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ALLEN DERMATOLOGY & SKIN CANCER CENTER
Name: _____________________________ Date of birth: ________________
IMPORTANT INFORMATION:
(Circle all that apply to you)
Problems with bleeding
Problems with healing
Problems with scarring (hypertrophic or
keloid)
Constipation
Nausea
Muscle aches
Somnulence
Changes in a mole or any skin lesion
Rash
Hormonal changes
Immunosuppression
Enlarged lymph nodes
Hay Fever
Dry eyes
Chest pain
Conjunctivitis
Fever or chills
Other:
Night sweats
__________________________
Unintentional weight loss
__________________________
Thyroid problems
__________________________
Sore throat
Blurry vision
Abdominal pain
Bloody stool
Bloody urine
Joint aches
Muscle weakness
Neck stiffness
Headaches
Seizures
Cough
Shortness of breath
Wheezing
Anxiety
Depression
Dizziness
Diarrhea