Name: ________________________ SKIN DISEASE HISTORY Acne Dry Skin Precancerous Moles □ □ □ □ Acne Keratosis □ Eczema □ Psoriasis (Pre-Skin Cancer) Flaking or Itchy Scalp Squamous Cell Carcinoma □ □ Basal Cell Carcinoma Melanoma Other _______________ ________________ □ □ □ Blistering Sunburns Poison Ivy None □ □ □ Do you wear sunscreen? Yes No If yes, what SPF? ____________ □ □ Do you use a tanning salon? Yes No □ □ Family history of melanoma? Yes No If yes, relative: _______________________ □ □ Medications (list all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements: Medication Name Dosage Frequency Route Drug Allergies: ___________________ __________________ ________________________ SOCIAL HISTORY Tobacco Products: Current every day smoker Former every day smoker Never □ □ □ Date Started/Quit _________ Alcohol: Less than 1 drink/day 1-2 drinks daily 3 or more drinks daily □ □ □ How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? ____________ Have you ever tested positive for TB? Yes No □ □ Name: ________________________
Name: ________________________ SKIN DISEASE HISTORY □ Acne □ Dry Skin □ Precancerous Moles □ Acne Keratosis □ Eczema □ Psoriasis (Pre-Skin Cancer) □ Flaking or Itchy Scalp □ Squamous Cell Carcinoma □ Basal Cell Carcinoma □ Melanoma □ Other _______________ ________________ □ Blistering Sunburns □ Poison Ivy □ None Do you wear sunscreen? □ Yes □ No If yes, what SPF? ____________ Do you use a tanning salon? □ Yes □ No Family history of melanoma? □ Yes □ No If yes, relative: _______________________ Medications (list all prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary supplements: Medication Name Dosage Frequency Route Drug Allergies: ___________________ __________________ ________________________ SOCIAL HISTORY Tobacco Products: □ Current every day smoker □ Former every day smoker □ Never Date Started/Quit _________ Alcohol: □ Less than 1 drink/day □ 1-2 drinks daily □ 3 or more drinks daily How many times in the past year have you had 5 or more drinks in a day for men, or 4 or more drinks in a day for women or any adult older than 65? ____________ Have you ever tested positive for TB? □ Yes □ No Name: ________________________