Patient Demographic Form Page 2
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Patient Name: ____________________________
□Native American
□Asian
□Black/African-American
□Pacific Islander
□White
□Decline
Race:
□Hispanic/Latino
□Non-Hispanic/Latino
□Decline to answer
Ethnicity:
Primary Language:______________________________________________________________________________
At which phone number do you prefer to be contacted? □Home
□Cell
□Work
*******************************************************
Preferred Pharmacy:____________________________________________________________________________
Pharmacy Address:_____________________________________________________________________________
Pharmacy Phone Number:________________________________________________________________________
MEDICAL HISTORY INFORMATION
HISTORY OF:
□ None of the below
□ None of the below
Melanoma
Hypertension
Dysplastic Nevi
Hypercholesterolemia
Other Skin Cancer
Diabetes
Adhesive Tape Allergy
Heart disease
Latex Allergy
Kidney disease
Reaction to Local Anesthetics
Thyroid disease
Epinephrine Sensitivity
Lupus
Bacitracin Allergy
Arthritis
Currently pregnant
Psoriasis
Currently nursing
Poor wound healing
Anticoagulant/Blood thinner
HSV-cold sore
Pacemaker/defibrillator
Eczema
Immunosuppressed
Asthma
Pre-op antibiotics
Hay fever
Hepatitis C/HIV
Other:
□ None
SURGERIES: Do not include normal pregnancies.
Date
Reason for surgery
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