BCD New Patient Intake Form Revised 09.08.2021mn

New Patient Intake Form

Welcome To Bold City Dermatology! Please fill out all fields of the form.
Date

MonthDayYear
Date
PERSONAL INFORMATION:
Name*

First NameLast Name
Marital Status
SSN
Date of Birth*

MonthDayYear
Date
Gender

MaleFemale
Address*
Apt/Unit
City*
State*
Zip*
Preferred Telephone #*
Please indicate your PREFERRED telephone number type:

HomeCellWorkOther
Alternative Telephone Number:
Please enter a valid phone number.
Please indicate your ALTERNATIVE telephone number type:

HomeCellWorkOther
Email Address*
example@example.com
Preferred Contact Method ( Select one)

PhoneE-mailPatient PortalLetterFax
Is it OK for us to leave a detailed message?

YesNo
IF it is okay for us to leave a detailed message, which phone number is preferred?

Preferred listed numberAlternate listed numberOther
Race ( Please select)*

American Indian or Native AlaskanAsianMiddle EasternNative Hawaiian / Pacific IslanderWhiteBlack /African AmericanDeclineOther
Retired*

YesNo
Language: Select all that apply*

EnglishSpanishDeclineOther
Employer
Ethnicity ( Please select )*

Hispanic / LatinoNot Hispanic / latinoDecline
Occupation
Industry
Emergency Contact and Authorization to share Medical Information:
Name
Relationship
Phone #
You have my permission to share medical results/information with the above person:*

YesNo
Any other authorized person Name
Relationship
Phone
Primary Care Doctor*
Referring Doctor*
Preferred Pharmacy: (Include city and street or street intersection):
Name*
City/Street*
Phone (if known)
Height*
Weight*
PAST MEDICAL HISTORY
Past Medical History ( Select all that Apply)*

AnxietyArthritisAsthmaArterial FibrillationBone Marrow TransplantBenign Prostate HyperplasiaBreast CancerColon CancerCOPDCoronary Artery DiseaseDepressionDiabetesEnd Stage Renal DiseaseGERDHearing LossHepatitisHypertensionHIV/AIDSHypercholesterolemiaHypERthyroidismHyPOthyroidismLeukemiaLung CancerLymphomaProstate CancerRadiation TherapySeizuresStrokeNoneOther
PAST SURGERIES: (Select all that apply and indicate year, if known)
Have you had any of the following skin conditions ( select all that apply)*

NoneAcneAsthmaActinic KeratosisBasal Cell CancerBlistering SunburnsDry skinEczemaFlaking or Itchy scalpHay Fever / AllergiesMelanomaPoison IvyPrecancerous MolesPsoriasisSquamous Cell CancerOther
Do you use sunscreen*

YesNo
If yes, indicate the SPF used
Do you tan in a tanning salon?*

YesNo
Please indicate if you have a family history of the following:

Notate which relative(s) have had the following condition
Melanoma *
Type Yes / No
If yes, which relative(s)?
Other Skin Cancers? *
Type Yes / No and Indicate type of cancer or condition
If yes, which relative(s)?
Other Diseases?
If yes, which relative(s)?
Medication Allergies/Reaction: (Please indication allergies to medications and your reaction)

No Known Drug Allergies
Please list all drug allergies in the space below
Alcohol and Smoking History
Male: How many times in the last year did you have 5 or more drinks in a day?*
Female: How many times in the last year did you have 4 or more drinks in one day?*
How many packs/day*
What is your smoking status?*

Never SmokedFormer SmokerCurrent everyday smoker
If current Smoker: What is the total Yrs. smoking? *
Medications: (Please list (name/dosage/route/frequency) or provide us your medication list)

Medication History

	Name of Medication	Dosage	Route	Frequency
1. Medication
2. Medication
3. Medication
4. Medication
5. Medication
6. Medication
7. Medication
8. Medication
9. Medication

Do any of the following apply to you:
Do you have any of the following (Please select all that apply):*

NoneProblems with healingProblems with scaringRashHay FeverFever / chillsNight SweatsUnintentional weight lossThyroid problemsChest PainSore ThroatBlurry VisionAbdominal PainBloody StoolBloody UrineJoint AchesMuscle WeaknessNeck StiffnessHeadachesSeizuresCoughShortness of BreathWheezingAnxietyDepression
Do any of the following apply to you: Select all that apply*

NoneAllergy to latexDifibulatorPacemakerBlood thinnerArtificial heat valveArtificial joints with in the last two yearsPremedication prior to proceduresAllergy to adhesiveAllergy to lidocaineRapid heartbeat with epinephrineAllergy to topical ointmentsMRSAPregnancy or planning pregnancyProblems with bleedingImmunosuppressionHistory of HepatitisHistory of HIVOther
Would you allow a medical student and or resident physician to observe during your visit?*

YesNo
Have ever received a pneumonia vaccination?*

YesNo
NO, if not why?*
Have you received the Flu immunization in the last year?*

YesNo
NO, if not why?*
Do you have a surrogate decision maker?*

YesNo
Surrogate Decision Maker Name*
Surrogate Decision Maker Phone Number*
Please enter a valid phone number.
Name of Primary Ins. Policy*
Insurance Policy No.*
Group Number *
Insurance Phone Number
Subscriber Name*

First NameLast Name
Subscriber DOB*
Subscribers Relationship to Patient*
Secondary Insurance Information
Name of Secondary Ins. Policy
Insurance Policy No.
Group Number
Insurance Phone Number
Subsriber Name
Subscriber DOB
Subscribers Relationship to Patient

Past Surgeries :

	Yes	If Yes, What year	Left / right /both
Appendix Removal
Bladder ( Cystectomy
Breast Biopsy
Lumpectomy
Mastectomy
Colon resection
Colectomy
Gallbladder removal
Heart : Valve replacement
Heart: Coronary Artery Bypass
Heart Transplant
Mechanical Valve Replacement
Heart Cath / Stents
Joint Replacement: Hip
Joint Replacement: Knee
Kidney: Biopsy
Kidney Stone Removal
Kidney Transplant
Kidney Removal
Liver Removal
Liver Transplant
Liver Shunt
Removal of ovaries: Endometriosis
Removal of ovaries: Cancer
Ovarian Ovarian Cyst removal
Tubal ligation
Prostate Cancer
Prostate Removal
Pancreas removal
TURP
Abdominoperineal resection
Lower anterior resection
Basal cell carcinoma Removal
Skin Biopsy
Squamous cell carcinoma removal
Melanoma Removal
Removal of spleen
Testical Removal
Uterus Removal
Uterine Cancer
Cervical Cancer

Should be Empty:

New Patient Intake Form

PERSONAL INFORMATION:

Alcohol and Smoking History