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					                          BOULDERDERMATOLOGY

                         Historvand IntakeForm p.l of 2

Name:
Date of Birth:
Today's Date:


Your Skin Disease His         ease circle all that   )
Acne                         Drv Skin                     PoisonIvy
Actinic Keratoses            Eczema                       PrecancerousMoles
Asthma                       Flakineor Itchy Scalp        Psoriasis
BasalCell Skin Cancer        FIavFever/Allersies          Squamous  Cell Skin Cancer
BlisterinqSunburns           Melanoma                     Oral Herpes(Cold sores)

Do vou currentlv haveanv of the followins? (circleall that applv)
Problemswith                Problemshealing                 Hypertrophic or keloid scars
bleedine/bruisins                                           (raised,lumpyscars)
       h
Explain ere:


Do you wearSunscreen? Yes No                If yes,what SPF?
Do you tan in a tanningsalon? Yes No

Do you havea family historyof Melanoma? Yes No
If yes.which relative(s)?

Any otherfamily history of skin cancer'/


Medications:(Please
                  enterall currentmedications)




Drus Allergies(list drugs and reactions):




Allergy to lidocaine? Yes No
Allergy to epinephrine? Yes No
                    or
Allergy to adhesives topical antibiotics? Yes     No
                           BOULDER DERMATOLOGY

                         Historv and Intake Form" p.2 of 2

Name:
Date of Birth:
Todav's Date:

SocialHistory: (Please
                     circle all that apply)

lllicit Drus Use                Alcohol Use                 Cisarette Smokine
No Drug Use                     Alcohol:none                Never smoked
IV DrueUse                      Alcohol: <l drink per dal   Quit: former smoker
OtherDruu Use                   Alcohol: l -2 drinksa dav   Smoker
                                Alcohol:>3+ per day

PastMedical His         :(      circleall that
Anxietv                         Depression                   Lun{rCancer
Arthritis                       D abetes                     Lvmohoma
Asthma                           K dnev Disease              ProstateCancer
Atrial fibrillation             GERD - acid ref'lux          RadiationTreatment
BPH - prostate    enlargement   Hepatitis                    Seizures
BoneMarrow                       Hish Blood Pressure         Stroke
Transplantation
BreastCancer Left or Risht  HIV/AIDS                         Defibrillator
ColonCancer                 Hiuh cholesterol                 Pacemaker
Emphysema/ COPD             Low Thyroid Levels
HeartAttack I Heart Disease Hish Thvroid Levels              None ofabove
                            Leukemia
Other:


PastSu        Histo     easecrrcle all that a
Mastectomy breast
            or                                                       due
                            Heart Valve Replacement Hysterectomy to uterine
lumoectomv  due to cancer                                cancer
Colon resection to colon Joint replacementin last 2 Ovariesremoveddue to
                due
      or
cancer bowel disease        Years- list ioint below      ovariancancer
Coronary artery bypass      Organtransplant:kidney, liver, heart
Other:


For femalesonly: Are you currently pregnant or planning pregnancy? Yes            No
Are you currently breastfeeding?
                               Yes No


t0/2012

				
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