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Affiliated Dermatology速 20401 N. 73rd St., Suite 230, Scottsdale, AZ 85255 13995 W. Statler Blvd., Suite 150 Surprise, AZ 85374 41810 N. Venture Dr., Suite D-136 Anthem, AZ 85086 19646 N. 27th Ave, Suite 305, Phoenix, AZ 85027 480-556-0446 phone 480-556-0447 fax Today's Date _ _ _ _ _ _ _ _ __ First Name _ _ _ _ _ _ _ _ _ __

M.I. ___ Last Name _ _ _ _ _ _ _ _ _ _ _ __

Parent or Legal G u a r d i a n - - - - - - - - - - - - - - - - - - Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Apt# _ _ _ _ _ _ _ _ ___ C i t y - - - - - - - - - - - - - - - - - State ______ Zip Code _ _ _ _ _ _ _ __ Home Phone _ _ _ _ _ _ _ _ _ Work Phone _ _ _ _ _ _ _Other Phone _ _ _ _ _ _ __ Social Security Number _ _ _ _ _ _ _ _ __

Date of Birth _ _ _ _ _ _ __

Male I Female

Email A d d r e s s - - - - - - - - - - - - - - - - - - Primary Care Physician Name and Phone N u m b e r - - - - - - - - - - - - - - - - - - - - - Did your PCP refer you? yes

I no

How did you hear of Affiliated Dermatology速 _ _ _ _ _ _ __

INSURANCE INFORMATION MUST BE COMPLETED - EVEN IF WE HAVE A COPY OF YOUR CARD!! Primary Insurance _ _ _ _ _ _ _ _ ___

Secondaryinsurance _ _ _ _ _ _ _ __

Policy Holder N a m e - - - - - - - - - - (This is the person who pays for policy from their employer)

Policy Holder N a m e - - - - - - - - - - (This is the person who pays for policy from their employer)

Policy Holder's ID# - - - - - - - - - - (This is sometimes the social security number of the policy holder)

Policy Holder's ID# - - - - - - - - - - (This is sometimes the social security number of the policy holder)

Group# _ _ _ _ _ _ _ _ _ _ _ _ _ __

Group#--------------

Patient Relationship to Policy Holder o son

o self

o self o spouse o daughter

Patient Relationship to Policy Holder o spouse o daughter o son

In case of Emergency, who should be notified? - - - - - - - - - - - - - - - - - - - - Phone Number Name Relationship Pharmacy of C h o i c e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Phone Number Name Location


MEDICAL HISTORY Patient N a m e : - - - - - - - - - - - - - - - - - - - - - - -

Date _ _ _ _ _ _ _ _ _ __

What is/are your main reason(s) for today's visit? - - - - - - - - - - - - - - - - - - - - - - - - - - -

Do you have now or have you ever had any of the following diseases or conditions:

No

Yes

Yes

Seasonal Allergies/Hay Fever Bronchitis Emphysema Asthma Chronic Cough Morning Cough Hlgh Blood Pressure Chest Pain Heart Valve Replacement Mitral Valve Replacement Heart Attack Heart Murmur Irregular Heart Beat Fainting/Dizzy Spells Phlebitis/Thrombosis Blood Clots

No

cancer HIV {AIDS) Herpes Simplex Virus Diabetes Thyroid Kidney Bladder Stomach/ulcers Colon/bowel disease Hepatitis or yellow skin Glaucoma Arthritis/Joint Deformity Seizures Pacemaker Tuberculosis Rheumatic Fever Joint Replacement

Please list ALL medications that you are currently taking or have taken within the last 7 days. This includes: prescriptions, over-the-counter medications, vitamins and supplements (internal or topical).

Are you allergic to any medications or local anesthetics? Yes 1 No

If yes, please list: - - - - - - - - - - - - - - - -

Are you allergic to latex? Yes 1 No Have you had a blood transfusion? Yes I No

Skin History When you are exposed to sun without sunscreen do you: Have you ever had skin cancer? Yes 1 No

Tan Only 1 Burn and Tan 1 Burn ?

If yes, please circle: basal cell

I squamous cell 1 melanoma

Has anyone in your family had a malignant melanoma? Yes 1 No If yes, please list who? - - - - - - - - - - - - - - Do you have a history of any specific skin diseases or skin problems? Yes I No - - - - - - - - - - - - - - - - - - -

List any other disease(s) we should know a b o u t : - - - - - - - - - - - - - - - - - - - - - - - - - - - - - List any surgical procedures you have had in the last six months: Is there a history of raised scarring after injury or surgery? Yes 1 No Do you bleed easily? Yes

I

No Are you taking any blood thinning medications such as aspirin or Coumadin? Yes 1 No

Do you pre-medicate for any medical procedures? (such as prescribed antibiotics) Yes 1 No

Social Historv Do you smoke or have you ever smoked? Yes Do you use IV drugs? Yes

I

No

I

No

If yes, how much? _ _ _ _ _ _ _Quit D a t e - - - - - - - - -

Do you drink alcohol? Yes I No If yes, how much? _ _ _ _ _ _ _ _ __

Patient reg forms  
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