PATIENT INFORMATION SHEET

First Name:

Last Name:

Address:

City:

Zip:

Date of Birth:
(Enter numbers only as mm/dd/yyyy, no slashes)

How Should We Address You?
(i.e., Mr/Mrs/first name/nickname)

Home Phone:
(Enter numbers only)

Work or Cell Phone:
(Enter numbers only)

Email:

Social Security #:
(optional)

Sex:

Marital Status:

Name of Referring Physician:
(if applicable)

Name of Primary Care Physician:

Primary Insurance:

Office Visit Co-Pay:

$

Secondary Insurance (if applicable):

Office Visit Co-Pay:

$

Cardholder/Subscriber Name:

Date of Birth:
(Enter numbers only as mm/dd/yyyy)

Social Security #:
(optional)

Sex:

Relationship to Patient:

Pharmacy Name:

Pharmacy Phone Number:
(Enter numbers only)

Pharmacy Address:

Pharmacy City:

Reason for Today's Visit:

GENERAL MEDICAL HISTORY

(please check if relevant)

Allergies to Medications:

Other Illnesses or Conditions of Significance:

Please list your medications:
(including estrogen replacement, birth control, aspirin and herbal supplements)

For Females:

Are your periods regular?

 Yes   No

Are you breastfeeding?

 Yes   No

Pregnancy Status?

 Yes   No   Trying

GENERAL SURGICAL HISTORY

(please check if relevant)

Do you need to take antibiotics prior to surgical/dental procedures?

 Yes   No

Prolonged bleeding during/post surgery?

 Yes   No

Keloid scars?

 Yes   No

Poor wound healing?

 Yes   No

Do you faint easily?

 Yes   No

PREVIOUS SKIN PROBLEMS

(please check if relevant)

FAMILY HISTORY

(please check if relevant)

SOCIAL HISTORY

What is your occupation?

Do you smoke?

How much alcohol do you drink?

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