PATIENTINFORMATION:

Name:______________________________________________________ DOB(mm/dd/yy):______/______/______

Email:__________________________ PharmacyName&Phone:_________________________/___________________PASTSKINHISTORY:(pleasecircleallthatapply)

Historyofnon-melanomaskincancer?YesNo Ifyes,type(s)andlocation(s)_______________________________

Historyofmelanoma?YesNo Ifyes,locationandyear__________________________________

Familyhistoryofmelanoma?YesNo Ifyes,relationship?______________________________________LISTOFMEDICATIONS/SUPPLEMENTS:(pleaselistdosageandfrequency)Medication(s)/Supplement(s): Dosage: Frequency:

1.____________________________ __________________________ ___________________________

2.____________________________ __________________________ ___________________________

3.____________________________ __________________________ ___________________________

4.____________________________ __________________________ ___________________________

5.____________________________ __________________________ ___________________________

6.____________________________ __________________________ ___________________________

7.____________________________ __________________________ ___________________________

8.____________________________ __________________________ ___________________________USEOFNARCOTICS:(pleasecircleallthatapply)Yes No If"Yes",doyourequireastoolsoftener?: Yes NoALLERGIES:MedicationAllergies:(pleaselist)

1._____________________________________________ 3._____________________________________________

2._____________________________________________ 4._____________________________________________

Latex: Yes No

HaveyoueverhadPoisonIvy: Yes NoSOCIALHISTORY:

Doyouusetobacco: Yes No Formersmoker

If"Yes": Currenteverydaysmoker Currentsomedaysmoker

DoyouconsumeAlcohol?: Yes No

If"Yes": Lessthan1drinkperday 1-2drinksperday 3ormoredrinksperday

VACCINATIONHISTORY:

FluVaccination(thisyear): Yes No

Pneumococcal(Pneumonia)Vaccination: Yes No

*Howmanytimesinthepastyearhaveyouhad5ormoredrinksinadayformen,or4ormoredrinksinadayforwomenoranyadultsolderthan65?(pleasecircle)012345+

PLEASECHECKIF"YES":☐ Allergytoadhesive ☐ BloodThinners ☐ Rapidheartbeatwithepinephrine

☐ Allergytolidocane ☐ MRSA ☐ Pregnancyorplanningapregnancy

☐ Allergytotopicalantibiotic/ointments ☐ Defibrillator ☐ WestAfrica:TravelorContact

☐ Artificialheartvalve ☐ Pacemaker ☐ TraveltoEbolariskcountry

☐ Artificialjointsinthepasttwoyears ☐ PremedicationpriortoproceduresPASTMEDICALHISTORY(Selectanyofthefollowingmedicalconditionsthatyoucurrentlyhave):☐ None ☐ CoronaryArteryDisease ☐ Hyperthyroidism

☐ Anxiety ☐ Depression ☐ Hypothyroidism

☐ Arthritis ☐ Diabetes(LastHemoglobinA1C_____) ☐ Leukemia

☐ Asthma ☐ EndStageRenalDisease ☐ LungCancer

☐ AtrialFibrillation(IrregularHeartbeat) ☐ GERD ☐ Lymphoma

☐ BoneMarrowTransplant ☐ HearingLoss ☐ ProstateCancer

☐ BPH ☐ Hepatitis ☐ RadiationTreatment

☐ BreastCancer ☐ Hypertension ☐ Seizures

☐ ColonCancer ☐ HIV/AIDS ☐ Stroke

☐ COPD ☐ Hypercholesterolemia ☐ Other:_______________PASTSURGERIES:☐ None ☐ Liver:LiverTransplant

☐ Appendix(Appendectomy ☐ Liver:Shunt

☐ Bladder(Cystectomy) ☐ Ovaries(Oophorectomy):Endometriosis

☐ Breast:BreastBiopsy ☐ Ovaries(Oophorectomy):OvarianCancer

☐ Breast:LumpectomyRL ☐ Ovaries(Oophorectomy):OvarianCyst

☐ Breast:MastectomyRL ☐ Ovaries(Oophorectomy):TubalLigation

☐ Colon(Colectomy):ColonCancerResection ☐ Pancreas:Pancreatectomy

☐ Colon(Colectomy):InflammatoryBowelDisease ☐ Prostate(Prostatectomy):ProstateBiopsy

☐ Colon:Colostomy ☐ Prostate(Prostatectomy):ProstateCancer

☐ Gallbladder:(Cholecystectomy) ☐ Prostate(Prostatectomy):TURP

☐ Heart:BiologicalValueReplacement ☐ Rectum:APR

☐ Heart:CoronaryArteryBypassSurgery ☐ Rectum:LowAnteriorResection

☐ Heart:HeartTransplant ☐ Skin:BasalCellCarcinoma

☐ Heart:MechanicalValueReplacement ☐ Skin:Melanoma

☐ Heart:PTCA ☐ Skin:SkinBiopsy

☐ JointReplacement:HipLR ☐ Skin:SquamousCellCarcinoma

☐ JointReplacement:KneeLR ☐ Spleen(Splenectomy)

☐ Kidney:KidneyBiopsy ☐ Testicles(Orchiectomy)

☐ Kidney:KidneyStoneRemoval ☐ Uterus(Hysterectomy):Fibroids

☐ Kidney:KidneyTransplant ☐ Uterus(Hysterectomy):UterineCancer

☐ Kidney:Nephrectomy ☐ Uterus(Hysterectomy):CervicalCancer

☐ Liver:Hepatectomy ☐ Other:____________________________________