History and Intake Form
Past Medical History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Other (Including any other type of cancer or any other problems you see a doctor for or take medicine for)
Past Surgical History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skin Disease History:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you wear Sunscreen?
 
 
 
Do you tan in a tanning salon?
 
 
 
Do you have a family history of Melanoma?
 
 
Social History:
 
Cigarette Smoking:




 
Alcohol Use Per Day



 
 
How often do you exercise?




 
What is your caffeine use?




 
Patient Data:
 
Race:






 
Ethnicity:


 
Preferred Language


Pharmacy: