Health History Form

Name

Date of Birth

Email Address

Why are you here today?

Name & Address of Your MD

Past Medical History (Check all that apply):

Past Surgical History (Check all that apply):


Immunization History

TD/TDAP
Influenza (yearly)
HPV (Gardasil)
Pneumonia
Meningococcal
Shingles



Skin Disease History (Check all that apply):


Do you Wear Sunscreen?

Do you tan in a tanning salon?

Do you have a family history of melanoma?

-If yes, which relative(s)?

Medications (please list current medications, including supplements)

Allergies (please list all allergies)

Social History

Cigarette Smoking:
Alcohol Use:
Language:


Race:
Ethnicity:

Employer:

Occupation:


Pharmacy

Street

Town

Zip


Review of Systems:

Please check if you are currently experiencing any of the following:


Alerts:

Type in this Codecaptcha


By signing this form, I agree you may leave a message with test results or appointment reminders on my phone. I will inform you if this is not acceptable.

Signature
Date


Please note that if you are more than 10 minutes late for your appointment, your appointment may need to be rescheduled.

*Don't forget to fill out the new patient registration form!