Dermatology • Dermatologic Surgery • Mohs Surgery • Cosmetic Surgery
PATIENT INFORMATION
Patient Name: ______Date of Birth:______Age:______
Address: ______City:______State:______
Zip:______Sex: _____M ______F Email:______
Home Phone: ______Cell Phone:______
Preferred contact: ______Cell ______Home _____ Email
Emergency Contact Name: ______
Phone:______Relationship:______
Primary Care Provider:______Location:______
MEDICAL HISTORY
Do you have or have you ever had: (check all that apply)
___ Anemia ___ Arthritis ___ Asthma ___ Blood transfusion ___ Blood clots ___ Breathing disorders
___ Bruise easily ___ Cancer ___ Chemotherapy ___ Intestinal disorders ___ Depression ___ Seizures
___ Diabetes ___ Epilepsy ___ Artificial joints ___ High blood pressure ___ Glaucoma ___ Hay fever
___ Headaches ___ Hepatitis ___ HIV/AIDS ___ Infections (chronic) ___ Kidney disease ___ Liver disease/hepatitis
___ Lupus ___ STD ___ Tuberculosis ___ Mitral valve prolapse ___ Pacemaker ___ Stroke
___ Ulcers __ Thyroid disease ___ Bleeding ___ Neurological disorder ___ Unusual moles ___ Heart problems
___Skin Cancer ___Psoriasis ___ Hair loss ___Radiation treatment ___Eczema ___Organ transplant
Other pertinent medical history and recent surgeries or illnesses:
______
FEMALES ONLY: ___ Postmenopause / surgically sterile ___Currently taking oral contraceptives ___ Currently pregnant ___ Breast Feeding
ALLERGIES: ___None
___Aspirin ___Novocaine/anesthetic ___Iodine ___Latex ___Penicillin ___Sulfa
___Topical antibiotics (Neosporin/bacitracin) Other______
Smoker? ______No ______Yes ______Former Do you drink alcohol? ___No ___Yes Drinks per week______
CURRENT MEDICATIONS: ______
______
______
______
____________
Thank you for choosing Advanced Dermatology, Inc. Please fill out the back side of this form prior to your appointment. If you have questions or are unable to do this, please arrive 15 minutes prior to your scheduled appointment time so we can assist you. If you need to reschedule or cancel your appointment please let us know in advance.
Please bring the following items to your appointment:
· Current insurance cards
· Form of identification (drivers license, ID card, passport)
· Current medication list
· Form of payment for any required co-pay or deductible (cash, check, VISA or MC)
· THIS FORM
We look forward to serving you.
Sincerely,
YOUR APPOINTMENT IS SCHEDULED FOR: ______
At our office in: Madison Monroe Oakwood Village
6510 Grand Teton Plaza, Madison 608-826-0285 1123 16th Ave. Monroe 608-329-5773