History and Intake Form (P.1) Patient Name Date of Birth Past Medical History (Please check all that apply) Anxiety Depression Leukemia Arthritis Diabetes Lung Cancer Artificial Joints End Stage Renal Disease Lymphoma Asthma GERD Pacemaker/Defibrillator Atrial Fibrillation Hearing Loss Prostate Cancer Benign Prostatic Hypertrophy (BPH) Hepatitis Radiation Treatment Bone Marrow Transplantation Hypertension Seizures Breast Cancer HIV/AIDS Stroke Colon Cancer Hypercholesterolemia Valve Replacement COPD Hyperthyroidism None Coronary Artery Disease Hypothyroidism Other Past Surgical History (Please check all that apply) Appendix Removed Mechanical Valve Replacement Ovaries Removed, Ovarian Cancer Bladder Removed Biological Valve Replacement Prostate Removed, Prostate Cancer Mastectomy (Right, Left, Bilateral) Heart Transplant Prostate Biopsy Lumpectomy (Right, Left, Bilateral) Joint Replacement, Knee (Rt, Lft, Bi) TURP Breast Biopsy (Right, Left, Bilateral) Joint Replacement, Hip (Rt, Lft, Bi) Skin Biopsy Breast Reduction Joint Replacement with last 2 years Basal Cell Cancer Surgery Breast Implants Kidney Biopsy Squamous Cell Carcinoma Surgery Colectomy - Colon Cancer Resection Kidney Removed (Right, Left) Melanoma Surgery Colectomy - Diverticulitis Kidney Stone Removed Spleen Surgery Colectomy - IBD Kidney Transplant Testicles Removed (Right, Left, Bi) Gallbladder Removed Ovaries Removed, Endometriosis Hysterectomy, Fibroids Coronary Artery Bypass Ovaries Removed, Cyst Hysterectomy, Uterine PTCA None Other CallaDerm Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504 History and Intake Form (P.2) Patient Name Date of Birth Skin Disease History (please check all that apply) Acne Dry Skin Poison Ivy Actinic Keratosis Eczema Abnormal Moles Asthma Flaking or Itchy Scalp Psoriasis Basal Cell Skin Cancer Hay Fever / Allergies Squamous Cell Skin Cancer Blistering Sunburns Melanoma None Other Do you wear Sunscreen? Yes No Do you tan in a tanning salon? Yes No Do you have a family history of Melanoma? Yes No If Yes, what SPF? If Yes, which relative(s)? Medications (Please list all current medications) Do you take any type of blood thinner? Yes No Do you take aspirin daily? Yes No Are you allergic to Latex? Yes No Are you allergic to Iodine or Betadine? Yes No Allergies (Please list all allergies) Social History (Please check all that apply) Currently Smokes - Daily Has Never Smoked Currently Smokes - Not Daily Drug Use None Has Smoked in the Past CallaDerm Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504 Review of Systems Patient Name Date of Birth Do you have any of the following? Pacemaker Take Any Type of Blood Thinner Defibrillator Pregnant or Planning to get Pregnant Artificial Joints Replaced within the past 2 Years An Allergy to Lidocaine Artificial Heart Valve Experience Rapid Heartbeat with Epinephrine Require Premedication Prior to Surgery Experience Yeast Infections when taking Antibiotics An Allergy to Adhesive Experience G.I. Upset with Antibiotics An Allergy to Topical Antibiotic Ointments None Are you currently experiencing any of the following? Problems with Bleeding A Cough Problems with Healing Depression Problems with Scarring (Hypertrophic or Keloid) Fever or Chills Have any concern with Immunosuppression Headaches A Changing Mole Hay Fever A Rash (Diagnosed or Undiagnosed) Joint Aches Abdominal Pain Muscle Weakness Anxiety Neck Stiffness Bloody Stool Night Sweats Bloody Urine Seizures Blurry Vision Sore Throat Chest Pain Thyroid Problems Shortness of Breath Unintentional Weight Loss Wheezing CallaDerm Center for Medical and Surgical Dermatology • 8 Sheridan Square, Suite 110 • Kingsport, TN 37660 • www.calladerm.com • (423) 408-1504