Have you ever had skin cancer? What kind?

1. Patient::__________________________________________ DOB:_______________________ Have you ever had skin cancer? What kind?  I don’t know Has your parent, sibling, grandparent or child ever had melanoma?  I don’t know Have you ever had asthma?  I don’t know Have you ever had seasonal allergies or hayfever?  I don’t know Has anyone in your family had eczema?  I don’t know Has anyone in your family had asthma, seasonal allergies or hayfever?  I don’t know Do you now use or have you ever regularly used tobacco? Have you ever had hepatitis?  I don’t know Do you now have or have you ever had high blood pressure (hypertension)?  I don’t know Do you have a pacemaker or defibrillator? Do you have any joint replacements for which you need to take antibiotics for surgery? Are you pregnant or breastfeeding? Do you have trouble healing? Do you tend to bleed excessively? Do you have a tendency to form hypertrophic (enlarged) scars or keloids? Do you get an allergic reaction to bandages, bandaids, or antibiotic ointments? Do you have difficulty with oral antibiotics (e.g. nausea, diarrhea, yeast infections)? Have you been having headaches and/or dizziness? No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes  Basal Cell  Squamous Cell  Melanoma  Other Type: What other significant medical problems do you have (things like diabetes, heart disease, etc.)?  None To what medications are you allergic?  None 1. 2. 3. What medications do you currently take? (we only need names, not the dose or schedule)  None 1. 2. 3. How would you like to be addressed by the nurse when called in from the reception area ? ____________________ Please sign and date at EVERY visit:______________________/_________________________/_______________ ____________________/_____________________/_____________________/_________________/___________