<p>Past Medical History: (mark all that apply)</p><p> Anxiety  BPH  Depression  HIV/AIDS  Lymphoma  Arthritis (prostate)  Diabetes  High  Prostate  Asthma  Breast  End Stage Cholesterol Cancer Cancer  Atrial Renal  Hyperthyroidi  Radiation fibrillation  Colon Disease sm Treatment Cancer  Bone Marrow  GERD  Hypothyroidi  Seizures Transplantati  COPD  Hearing Loss sm  Stroke on  Coronary  Hepatitis  Leukemia Artery  Hypertension  Lung Cancer Disease   Other (specify) ______ None   Past Surgical History: (mark all that apply)  Appendix Removed  Heart: Biological Valve  Prostate Removed:  Bladder Removed Replacement Prostate Cancer  Breast: Mastectomy  Heart Transplant  Prostate Biopsy (Circle: Right, Left, Both)  Joint Replacement, Knee  Prostate: TURP  Breast: Lumpectomy (Circle: Right, Left, Both)  Skin Biopsy (Circle: Right, Left, Both)  Joint Replacement, Hip  Basal Cell Cancer  Breast Biopsy (Circle: Right, Left, Both) Surgery  Breast Reduction  Kidney Biopsy  Squamous Cell  Colectomy: Colon Cancer  Nephrectomy: Kidney Carcinoma Surgery Resection Removed (Circle: Right,  Melanoma Surgery Left)  Colectomy: Diverticulitis  Spleen Removed  Kidney Stone Removal  Colectomy: IBD  Testicles Removed  Kidney Transplant  Gallbladder Removed (Circle: Right, Left,  Ovaries Removed: Bilateral)  Heart: Coronary Artery Endometriosis Bypass  Hysterectomy: Fibroids  Ovaries Removed: Ovarian  Heart: PTCA  Hysterectomy: Uterine Cyst Cancer  Heart: Mechanical Valve  Ovaries Removed: Ovarian Replacement Cancer   Other (specify)______ None   Skin Disease History: (mark all that apply)  Acne  Blistering  Hay  Precancerous  Actinic Sunburns Fever/Allergies Moles Keratosis  Dry Skin  Melanoma Skin  Psoriasis  Asthma  Eczema Cancer  Squamous Cell  Basal Cell Skin  Flaking or Itchy  Poison Ivy Skin Cancer Cancer Scalp   Other ______ None   Do you have a family history of MELANOMA (NOT the same as basal cell or squamous cell carcinoma)? </p><p>Yes</p><p>No   If YES to melanoma, which relative(s)? ______ If YES to melanoma, any other family history (breast, ovarian, pancreatic or prostate cancers)?   ______   Have you had a Pneumonia Vaccine? Yes/NO (circle one) If Yes When? ______ Height ______Weight ______BMI ______  Medications: (enter all current medications and strengths) □ None  ______ Drug Allergies: (do they cause anaphylaxis, angioedema, diarrhea, fatigue, GI upset, hives, liver toxicity, or rash?)   ______</p><p> □ No Known Drug Allergies □ Latex  Social History: (mark all that apply)  Sexual History:  Sexually active with one  Sexually active with more  Not sexually active partner than one partner  Same Sex-Sexual partner  3 or more drinks per  Safety:  Illicit Drug Use: day  I feel safe at home.  Drug Use  How many times in the  I do not feel safe at home. past year have you had 4  IV Drug Use  or more drinks in a day?   Cigarette Smoking  Less than Twice per Year  (must answer):  More than Twice per  Alcohol (EtOH) Use:  Current every day smoker Year  None  Current some day smoker   Less than 1 drink a day  Former smoker   1-2 Drinks per day  Never smoker  Other______ Review of Systems: Are you currently experiencing any of the following? (Please check yes or no for the following)  Headaches Yes No  Dryness Yes No  Blurred Vision Yes No  Moodiness/Anxiety Yes No  Fever/Having signs of illness Yes No  Problems Healing/Scars Yes No   Other Symptoms: ______  Alerts: Are you currently using or experiencing any of the following? (Please check yes or no for the following)  Blood thinners Yes No  Currently using Accutane/Biologic Yes No  Allergic to adhesive Yes No  Premedication prior to procedures Yes No  Pacemaker Yes No  Artificial Joints within past 2 years Yes No  Are you pregnant Yes No  If yes, due date: ______  Other Symptoms: ______  PHARMACY (You may ALSO list your mail-order pharmacy - include PHONE and FAX number)   Name ______Zip Code (or nearby zip code) ______(This is the fastest way for us to search)   Address (or major cross-roads if not known): ______  Phone number: ______</p>