Name First Last Date of Birth MM slash DD slash YYYY Primary Physician Prior Dermatologist Health HistorySkin Cancer in the past (check type). *Referral Required Prior to Appointment Yes No Type Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma Unsure Basal Cell Carcinoma Year Squamous Cell Carcinoma Year Melanoma Year Have you ever received an organ transplant Yes No Have you ever received a pneumococcal vaccine Yes No Have you received a flu shot this year Yes No Are you currently on blood thinners Yes No Do you currently have a pacemaker or defibrillator Yes No Are you currently pregnant Yes No Do you have a health proxy/healthcare advocate Yes No Do you have a living will Yes No Family HistoryFamily history of skin cancer Yes No Type Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma Relation to You Social HistoryTobacco use Currently Use Used in the past Never Used List of current medications (*please include creams, lotions, ointments, etc.): Add RemoveUse the plus to add new lines as you need themAllergies to medications Pharmacy InformationRetail Name Mail Order Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Δ
