AnxietyArthritisAsthmaAtrial FibrillationBone Marrow TransplantationBPHBreast CancerColon CancerCoronary Artery DiseaseDepressionDiabetesEnd Stage Renal DiseaseOther (Enter Below)

Hearing LossHepatitisHypertensionHIV/AIDSHypercholesterolemiaHypothyroidismLeukemiaLung CancerLymphomaProstrate CancerRadiation TreatmentSeizuresStroke

Past Medical HistoryPlease select any of the following conditions that you currently have:

Physician List:Please list the name and location of your physicians:

1. Primary care physician:

2. Other:

3. Other:

4. Other:

Name: Birthdate:

Appedix (Appendectomy)Bladder (Cystectomy)Breast: mastectomy (right breast)Breast: mastectomy (left breast)Breast: mastectomy (both breasts)Breast: lumpectomy (right breast)Breast: lumpectomy (left breast)Breast: lumpectomy (both breasts)Breast: breast biopsyBreast: breast reductionBreast: breast implantsColon (colectomy): colon cancer resectionColon (colectomy): diverticulitisColon (colectomy): inflam. bowel diseaseGall bladder (cholecystectomy)Heart: coronary bypass surgeryHeart: coronary stent placementHeart: mechanical valveHeart: biological valveHeart: heart transplantJoint replacement: knee rightJoint replacement: knee leftOther surgeries (enter below)

Joint replacement: knee bothJoint replacement: hip rightJoint replacement: hip leftJoint replacement: hip bothKidney: kidney biopsyKidney: nephrectomyKidney: kidney stone removalKidney: kidney transplantOvaries (oophorectomy): endometriosisOvaries (oophorectomy): ovarian cystOvaries (oophorectomy): ovarian cancerProstate (prostatectomy): prostate cancerProstate: prostate biopsyProstate (prostatectomy): TURPSkin: skin biopsySkin: basal cell carcinomaSkin: squamous cell carcinomaSkin: melanomaSpleen (splenectomy)Testicles (orchiectomy)Uterus (hysterectomy): fibroidsUterus (hysterectomy): uterine cancer

Past SurgeriesPlease select any of the following surgeries that you have had:

AcneActinic KeratoesAsthmaBasal cell skin cancerBlistering sunburnsDry skinEczemaOther skin conditions:

Flaking or itchy scalpHay fever/allergiesMelanomaPoison ivyPrecancerous molesPsoriasisSquamous cell skin cancerLung Cancer

Skin Disease HistoryHave you had any of the following conditions?

Do you wear sunscreen?

Yes No

Do you tan in a tanning salon?

Yes No

If yes what SPF? ______

Do you have a family history of melanoma?

Yes No

If yes which relative ? ________________

Medications:1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Allergies:Please list any medication allergies you have and what your reaction was.

1.

Drug Reaction

2. 3. 4.