Transformations Skin & Body Solutions LLC

Transformations Skin & Body Solutions LLC

Please answer all the questions as accurately as possible. Please turn this sheet over and fill in the information on the back. Bring this form in with you to your appointment (DO NOT MAIL).

Last Name ______, First______RECORD #______Date______

Why were you referred to us? ______

What is your Age ______Sex:M / F

Which hand is your dominant one?RightLeft Use Both Equally

Do you have any Hobbies or Talents? Y / N What are they? ______

What are your DRUG ALLERGIES?

Drug Name ______Effect______

Drug Name ______Effect______

Drug Name ______Effect______

What are the MEDICATIONS YOU TAKE? _____ I take NO Medications at all.

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Drug Name ______Dose ______Times per day ______

Do you take aspirin or Ibuprofen daily or almost every day? Y / N

Skin Hx

Have you previously had skin cancer? Y / NIf so, circle: Basal Cell Squamous CellMelanoma

Do you have a family history of skin cancer? Y / N

Were you born in the South or lived here over 10 years?Y / N

Did you spend a lot of time outside in the sun?Y /N

Did you have any blistering sunburns ever? Y / N

Did you ever work outdoors? Y / N

Do you or have you used Tanning beds?Y / N

Do you or have you had Psoriasis?Y / N

Do you or have you had Warts?Y / N

Do you or have you had Cold Sores/Shingles (Zoster)?Y / N

YOUR OWN PAST MEDICAL HISTORY: Have you had? (Circle or fill in blank)

AnemiaAnxietyArthritisArtificial Joints/ImplantsAsthma

Bleeding DisorderCancer ______

DepressionDiabetesGlaucomaHeart DiseaseHeart valve disease

HepatitisHigh Blood PressureHIV/AIDSKidney DiseaseLiver DiseaseMRSA

Psychiatric/nervous illnessRadiation Therapy/Chemotherapy

SeizuresStomach ulcerStrokeThyroid DisorderTuberculosis

WHAT ARE YOUR PREVIOUS SURGERIES, MAJOR ILLNESSES, AND HOSPITALIZATIONS?

______I have never had any type of surgery, ever.

Date & Type ______Date & Type ______

Date & Type ______Date & Type ______

Date & Type ______Date & Type ______

FAMILY HISTORY:Have any immediate family members had? (Circle)

AdoptedAllergiesAnemiaArthritisAsthmaAutoimmune Disorders

Bleeding DisorderBreast CancerColon CancerCancer Other ______

Chemical dependencyCOPDDepressionDiabetesGlaucoma

Heart DzHeart Valve DzHigh Blood PressureHigh Cholesterol

Kidney DzLiver DiseaseLung DiseaseMelanoma

Psychiatric/nervous illnessSeizuresStroke

Thyroid DzTuberculosisOther ______

Last Name ______, First______RECORD #______Date______

What age did your mother die? ______What did she die from? ______

What medical problems did she have? ______

What age did your father die? ______What did he die from? ______

What medical problems did he have? ______

SOCIAL HISTORY:

Were you ever a smoker? Yes / No

If so, at the most how many packs per day did you smoke?1/41/2123

What year did you start? ______When year did you quit? ______

Have you travelled outside the United States recently? Y / NWhere ______

Do you use any illicit substances (ILLEGAL DRUGS) Y / N If so what ______

Chemical Exposure at work? Yes / NoIf so what ______

Do you drink any alcohol almost daily? Yes / NoIf so how many drinks per day? ______

How many times in the past year have you had 5 (for men) or 4 (for women) or more drinks in a day ______

Have you had a Flu ShotYes / No If yes at work or home (Circle)

If not why (Circle) Do not want AllergyNo ReasonNot Available

REVIEW OF HEALTH SYSTEMS:Do you have now or had within the past year?(Circle)

Easy BleedingEasy BruisingAnemiaEnlarged Glands

Chronic CoughWheezingCongestionShortness of Breath

DiabetesLoss of HairHeat/Cold Intolerance

Sore ThroatSinus TroubleStuffy NoseHearing LossNose Bleeds

Head AchesMemory LossLoss of StrengthParalysisNumbness

Chest PainDizzinessShortness of BreathHigh Blood PressurePalpitations

Acid RefluxNausea/VomitingChange in AppetiteAbdominal PainConstipationDiarrhea

Joint Pain/SwellStiffnessMuscle PainBack Pain

Frequent UrinationPainful UrinationBloody UrineDischargeBladder Leakage

HivesEczemaHay fever

Blurred VisionEye IrritationDry Eyes

AnxietyDepressionMood SwingsDifficulty SleepingHomicidal Thoughts Suicidal Thoughts

What do you Weigh in pounds? ______What is your Height in inches ______

If you have a Cardiologist what is His / Her name? ______

WOMEN ONLY:

Date of Last Period ______Number of Pregnancies ______Date Last Mammogram ______

Is there any reasonable chance you are pregnant? Yes / No

****YOU ARE RESPONSIBLE FOR COMPLETING THIS FORM Transformations Skin & Body Solutions AND ITS EMPLOYEES ARE NOT RESPONSIBLE FOR PROBLEMS ARISING FROM YOUR ERRORS and

OMISSIONS****

I VERIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE:

Signature of Patient or Guardian: ______Date: ______/_____/______