A beacon for patient care

Transcription

1 A beacon for patient care Welcome to our practice! At Beacon Skin & Surgeries, patient care is our top priority. We strive to offer outstanding services in the area of dermatologiconcology and skin cancer Mohs Micrographic Surgery. If you were referred from another dermatologist, please be aware that we will only treat the skin cancer your dermatologist diagnosed. You will be referred back to your dermatologist s office for all other dermatologic/cosmetic needs. Please see the maps below for directions to our offices. Our Rochester Hills office is our main location with our sister practice in Dearborn. We look forward to treating you. 110 W. South Blvd Suite Ford Road Rochester Hills, MI Dearborn, MI Office:

2 INSTRUCTIONS: PLEASE FILL OUT THE FOLLOWING FORMS COMPLETELY AND MAIL BACK IN RETURN ENVELOPE OR FAX TO THANK YOU. Demographics: Full Name: Address: State: Date of Birth: City: Zip Code: Gender: Primary Phone #: Secondary Phone #: Race: Emergency Contact Name: Decline to specify White Black or African American Emergency Contact Relation: American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Emergency Contact Phone #: Hispanic Other: Ethnicity: Address: Declined to specify Not Hispanic or Latino Hispanic or Latino Preferred Language: Social Security #: Referring Physician: Primary Care Physician: Referring Physician Phone #: Primary Care Physician Phone #: Referring Physician Address: Referring Physician Address: Insurance Information: Primary Insurance: Name of Insurance: Policy Type: Member ID #: Group #: Policy Holder Name (If not self): Relationship To Policy Holder:

3 Policy Holder Gender: Policy Holder DOB: Secondary Insurance: Name of Insurance: Policy Type: Member ID #: Group #: Who referred you to our office or how did you hear of us? Please list the name, phone number and fax of any doctors (besides the referring physician and primary care physician listed above) who should receive a note about today s visit. Please list the name, city, zip code, and phone number of your preferred pharmacy (s): Past Medical History: Select any of the following medical conditions that you have currently: Anxiety Breast Cancer End Stage Renal Disease Hypercholesterolemia Prostate Cancer Arthritis Colon Cancer GERD Hyperthyroidism Radiation Treatment Asthma COPD Hearing Loss Hypothyroidism Seizures Atrial Fibrillation (Irregular Heartbeat) Coronary Artery Disease Hepatitis Leukemia Stroke Bone Marrow Transplantation Depression Hypertension Lung Cancer Other:(please explain) BPH Diabetes HIV/AIDS Lymphoma None Past Surgeries: Please list any prior surgeries or procedures (don t forget any heart, joint, skin surgeries, C-section, tubal ligation, or hysterectomy): Skin Disease History: Have you had any of the following skin conditions: Acne Blistering Sunburns Hay Fever/Allergies Psoriasis Actinic Keratosis Dry Skin Melanoma Squamous Cell Skin Cancer Asthma Eczema Poison Ivy Other: (Please explain) Basal Cell Skin Cancer Flaking or Itchy Scalp Precancerous Moles None If you have had Basal Cell, Squamous Cell or Melanoma skin cancer in the past, please specify the location, how it was treated, when it was treated and who treated it.

4 Do you wear sunscreen? YES (if yes, what SPF? ) NO Do you tan in a tanning salon? YES NO Family History: Do you have a family history of Melanoma? No Yes If yes, which relative? Mother Daughter Nephew Grandson Father Son Niece Granddaughter Sister Uncle Grandmother Other Brother Aunt Grandfather None Do you have a family history of heart attack or stroke? Please specify which family member. Allergies: Are you allergic to any medication? YES NO If yes, please list the date or year that you had the reaction and what type of symptoms (i.e. rash, itching, hives, shortness of breath, nausea) Social History: Do you smoke or chew tobacco? Yes If yes, please explain: No Quit If quit, please explain: Do you drink alcohol? Yes If yes, please explain No Quit If quit, please explain: How often do you exercise? What is your caffeine intake? General Questions: Do you have a pacemaker? Do you have a defibrillator? Do you have artificial joints? Do you have artificial heart valve? Do you take premedication prior to procedures? Are you allergic to topical antibiotics? Are you on blood thinner? Do you have other bleeding problems? Do you get rapid heartbeat with epinephrine? Do you get yeast infection with antibiotic? Do you get GI upset with antibiotics? Are you allergic to lidocaine? Do you have anxiety (at doctor s office)? Do you have a changing mole? YES NO If yes, explain and provide dates:

5 Do you have a rash? Do you have problems with healing? Do you have nausea or upset stomach? Do you have chest pain? Do you have a cough? Do you have a fever or chill? Do you have headaches? Do you have joints pain? ************************************************************************************************** Female Patients Only (This applies to all females age 10 and older) Are you pregnant? Yes NO If yes, explain: Are you planning a pregnancy? Yes NO If yes, explain: When is the last day of your last period (or last period if menopausal)? If you are avoiding pregnancy, what method are you using? (i.e. birth control pills, IUD, abstinence, Depo- Provera, condoms) Are you breast feeding Yes NO If yes, explain: **************************************************************************************************

6 Medications: THIS IS VERY IMPORTANT! Please list your medications and supplements, with the month and year that you began each medication. It is imperative that you fill this table out COMPLETELY and to the best of your ability. Don t forget over the counter products like Aspirin, Ibuprofen and Tylenol. Also, please write any medication you have stopped within the last 6 months. Medication Name Dosage Frequency Route (ex. Oral/IV) Date Began Date Ended