Scott D. Warren, MD, PA

First Coast Mohs First Coast Mohs Dermatology Associates of FCM

6890 Belfort Oaks Place 216 Ponte Vedra Park Dr 9905 Old St. Augustine Rd

Jacksonville, FL 32216 Ponte Vedra Beach, FL 32082 Jacksonville, FL 32257

904-296-1313 904-296-1313 904-880-7715

PQRS is the federal program that all providers are required to report in addition to all other information to complete your healthcare visit. Failure to report will lead to penalties imposed by the federal government. Please take a moment and answer the below questions. Thank you.

NAME:______DATE OF BIRTH:______

History and Intake Form

Past Medical History: (please circle all that apply)

EMA Intake 2015 v.1

Anxiety

Arthritis

Artificial Heart Valve

Artificial joints

Asthma

Atrial fibrillation

BPH (Benign Prostatic Hyperplasia)

Bone Marrow Transplantation

Breast Cancer

Chemotherapy

Colon Cancer

COPD (Emphysema)

Coronary Artery Disease

Depression

Diabetes

End Stage Renal Disease

GERD (Acid reflux)

Hearing Loss

Hemophilia

Hepatitis

Hypertension

HIV/AIDS

Hypercholesterolemia

Hyperthyroidism

Hypothyroidism

Leukemia

Lung Cancer

Lupus

Lymphoma

Organ Transplant

Pacemaker

Prostate Cancer

Radiation Treatment

Seizures

Stroke

Valve Replacement

None

EMA Intake 2015 v.1

Other:______

Have you had an influenza vaccine in the past 12 months (FLU SHOT)? YES / NO

Have you had a Pneumonia vaccine in the past 5 years (Pneumovax shot)? YES / NO

Past Surgical History: (please circle all that apply)

EMA Intake 2015 v.1

Appendix Removed

Bladder Removed

Mastectomy (Right, Left, Bilateral)

Lumpectomy (Right, Left, Bilateral)

Breast Biopsy (Right, Left, Bilateral)

Breast Reduction

Breast Implants

Colectomy: Colon Cancer Resection

Colectomy: Diverticulitis

Colectomy: IBD

Gallbladder Removed

Coronary Artery Bypass

PTCA

Mechanical Valve Replacement

Biological Valve Replacement

Heart Transplant

Joint Replacement, Knee (Right, Left, Bilateral)

Joint Replacement, Hip (Right, Left, Bilateral)

Joint Replacement within last 2 years

Kidney Biopsy

Kidney Removed (Right, Left)

Kidney Stone Removal

Kidney Transplant

Ovaries Removed: Endometriosis

Ovaries Removed: Cyst

Ovaries Removed: Ovarian Cancer

Prostate Removed: Prostate Cancer

Prostate Biopsy

TURP

Skin Biopsy

Basal Cell Cancer Surgery

Squamous Cell Carcinoma Surgery

Melanoma Surgery

Spleen Removed

Testicles Removed (Right, Left, Bilateral)

Hysterectomy: Fibroids

Hysterectomy: Uterine Cancer

None

EMA Intake 2015 v.1

Other: ______

Skin Disease History: (please circle all that apply)

EMA Intake 2015 v.1

Acne

Actinic Keratosis

Asthma

Basal Cell Skin Cancer

Blistering Sunburns

Dry Skin

Eczema

Flaking or Itchy Scalp

Hay Fever/Allergies

Poison Ivy

Precancerous Moles

Psoriasis

Squamous Cell Skin Cancer

None

EMA Intake 2015 v.1

Melanoma

Other:______

Do you wear Sunscreen?YES/NO If yes, what SPF? ______Do you tan in a tanning salon? YES/NO

List of all Medications /Dosages/ Strength/ Route Taken / (By Mouth, Injection and Topical).

How often you take them? (Please enter all/provide list current medications or write ONE): ______

______

Allergies: (Please enter all allergies or write NONE):

______

______

Social History:

EMA Intake 2015 v.1

Do you drink alcohol? YES/NO IF YES:

  1. Have you ever felt you should Cut down on your drinking? YES/NO
  2. Have people annoyed you by criticizing your drinking? YES/NO
  3. Have you ever felt bad or guilty about your drinking? YES/NO
  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? YES/NO

Do you smoke or use Tobacco?YES/NO IF YES:

  1. Never Smoked
  2. Quit: former smoker
  3. Smokes less than daily
  4. Smokes daily

How often do you exercise? What is your caffeine use?

Once a day Once a day

A few times a week A few times a week

A few times a month A few times a month

Never Never

Family History:Circle the following conditions that are in your immediate family

(Mother, Father, Brother, Sister)

Asthma High Cholesterol Lung Disease

Bleeding Disorders HypertensionLupus Mental Illness

Diabetes Kidney Disease Thyroid Disease

Heart Disease Liver Disease Seizures

Cancer: ______

(Please specify which kind)

Race: Language: Ethnicity:

White English Hispanic/Latino

Black/African American Spanish Not Hispanic/Not Latino

Asian Other: ______Decline to Specify

American Indian/Native Alaskan

Native Hawaiian/Pacific Islander

Pharmacy: Name:______Phone Number: ______

Address:______Zip:______

Review of Systems: (Please circle one) Alerts: (Please circle one)

Problems with bleeding Currently Pregnant

Problems with healing Planning on Becoming Pregnant

Problems with scarring NOT APPLICABLE

Problems with rash

NONE

Signature:______Date:______

EMA Intake 2015 v.1