Fillable New Patient Registration Form (Page 2 of 3) in pdf

MEDICAL QUESTIONNAIRE

Please fax to 916.784.7548 or send back to us PRIOR to your appointment

Name ____________________________________________________________________________________________________

Last

First

Reason for today’s visit ___________________________________________________________________________________

How long have you had this problem? ___________________________________________________________________________

Symptoms (how does it bother you?) ____________________________________________________________________________

Treatments you have tried ____________________________________________________________________________________

Current Medications — include prescriptions, over-the-counter meds (such as aspirin), vitamins, and herbal products:

__________________________________________________________________________________________________________

ALLERGIES to any medications? ! None ! Yes ____________________________________________________________

List name of medication and type of reaction

Pharmacy of choice _______________________________________________________________________________________

Name

Street name

City

MEDICAL HISTORY: Check below if you have or ever had any of the following diseases

! Artificial heart valve

! Cancer ________________

! High blood pressure

! Stroke

! Artificial joint

! Depression

! Kidney disease

! Thyroid disease

! Asthma

! Diabetes

! Liver disease/Hepatitis

! Other _________________

! Bleeding disorder

! Hayfever/seasonal allergies

! Lung disease

! Blood clots

! Heart disease

! Pacemaker

SKIN HISTORY

Have you had skin cancer?

! Yes ! No

If Yes, ! Melanoma

! Basal cell carcinoma

! Squamous cell carcinoma

! Yes, but don’t know type

Locations: _________________________________________________________________________________________

Treatments/Surgeries and Date: ________________________________________________________________________

Do you have a history of any specific skin diseases?

! Yes ! No

If yes please list, _____________________________________________________________________________________

When you are exposed to sunlight, do you:

! always burn (skin type 1)

! often burn, tan slowly (3)

! rarely burn, always tan (5)

! usually burn, rarely tan (2)

! sometimes burn, tan well (4)

! never burn, deeply tan (6)

Women only:

Are you pregnant? ! Yes ! No

Are you breastfeeding? ! Yes ! No

Are you trying to conceive? ! Yes ! No

FAMILY HISTORY: Please list any blood relative (parents, grandparents, siblings, and children) with a history of:

! Skin Cancer ___________________________

! Melanoma ___________________________

SOCIAL HISTORY

Do you drink alcohol? ! Yes ! No: If yes, _____ drinks/week

Do you smoke? ! Yes ! No: If yes, ____ packs/day

Have you recently had any of the following? REVIEW OF SYSTEMS (ROS)

! Allergy symptoms

! Hair loss

! Menstrual problems

! Shortness of breath

! Bleeding problems

! Heat/cold intolerance

! Palpitations

! Swollen lymph node

! Depression

! Joint pain

! Rash

! Weight change

I certify that the above information, to the best of my knowledge, is correct.

Signature ___________________________________________________________________ Date _______________________

1412 Blue Oaks Blvd | Roseville, CA 95747 | 916.784.7546 | Fax 916.784.7548 |

New Patient Registration Form Page 2

Related Articles

Related forms

Related Categories