Reason for visit
Are you allergic to any medications? If yes, please list:
List all medications you are currently taking:
Height and Weight
Please check any/all condition(s)/disease(s) below that you have now or have had in the past:
Artificial Heart Valve(s)
High Blood Pressure
Surgery in the Last 6 Months
If you answered yes to any of the above, please explain:
Do you drink alcohol?
If YES how many drinks per day?
Do you smoke cigarettes, cigars or e-cigarettes?
If yes, which and how much?
Do you use any non-prescription drugs?
If YES, what do you use? How often?
Are you allergic to lidocaine or novocaine?
When you are exposed to the sun, do you:
Tan and Burn
Have you ever had skin cancer?
Has anyone in your family had skin cancer? If yes, who?
If you have any specific skin disease please list:
List any other disease or condition we should know about:
(Women) Are you pregnant?
Trying to become pregnant
(Women) Are you nursing?
What is your occupation?
What are your hobbies?
Should be Empty: