Dermatology Associates of Central NJ & Freehold Skin Clinic & Cancer Center

Dermatology Associates of Central NJ &
Freehold Skin Clinic & Cancer Center
Patient Name:_______________________________________________________________________________
Why are you here today?__________________________________________________________________
Referring Physician: _______________________________________________________________________________
Referring Physician Phone #___(_______________)___________________-______________________________
Primary Care Doctor: ______________________________________________________________________________
Primary Care Phone #____(_______________)________________________-________________________________
Primary Care – MONTH/YEAR of last visit: _________________________ /__________________________
Have you been hospitalized since your last visit? YES or NO
If YES, please give reason for hospitalization: _________________________________________________
_________________________________________________________________________________________________________
Pharmacy Name:_______________________________________ Phone #__________________________________
Street:____________________________________________________ Zip code: ________________________________
Date of Birth: ___________________________ Gender: Female or Male
Female: Date of Last Menstrual Cycle __________________________________________________
Past Medical History: (please CIRCLE all that apply):
Anxiety End Stage Renal Disease Leukemia

Arthritis GERD Lung Cancer
Asthma Hearing Loss Lymphoma
Atrial fibrillation Hepatitis Prostate Cancer
Bone Marrow Transplant High Blood Pressure Radiation Treatment
BPH HIV/AIDS Seizures
Breast Cancer High Cholesterol Stroke
Colon Cancer Thyroid Problems (Hyper or Hypo) Pacemaker
Chronic Obstructive Depression NONE
Do you have any of the following? (Please CIRCLE all that apply):
HEART FAILURE DIABETES COPD (Pulmonary Disease) CAD (Coronary Artery Disease)
Past Surgical History: (please list all that apply):
___________________________________________________________________________________________________________________
Skin Disease History: (please CIRCLE all that apply):
Acne Dry Skin Poison Ivy

Actinic Keratosis Eczema Precancerous Moles
Asthma Flaking or Itchy Scalp Psoriasis
Basal Cell Skin Cancer Hay Fever/Allergies Squamous Cell Skin Cancer
Blistering Sunburns Melanoma NONE
Do you wear Sunscreen? Yes No

If yes, what SPF? ___________
Do you tan in a tanning salon? Yes No
Do you have a history of Melanoma? Yes No
Do you have a family history of Melanoma? Yes No

List all that apply: Mother Father Sister Brother Daughter Son Other
Medications: (Please enter all current medications):

__________________________________________DOSE______________________FREQUENCY_____________________________________________
__________________________________________DOSE______________________FREQUENCY_____________________________________________
__________________________________________DOSE______________________FREQUENCY_____________________________________________
__________________________________________DOSE______________________FREQUENCY_____________________________________________
__________________________________________DOSE______________________FREQUENCY_____________________________________________
Allergies: (Please enter all allergies, including medication allergies):

__________________________________________________________________________________________________________________________________
All Patients Patients 12 and older
Have you received the flu vaccine this year? Tobacco Use:
□ Yes □ Smoker
□ No (Reason: _____________________ ) □ Non-smoker
Do you have a history of Melanoma?

□ Yes
□ No
Patients 65 and older
Are you on a biologic (ex: Stelara) for psoriasis? Do you have an Advance Care Plan/Directive?
□ Yes (please name your Surrogate Decision
□ Yes
Maker: ____________________________
□ No
□ Decline to answer
List current height and weight. Have you EVER received the pneumonia vaccine?
Height: ____ ft _____ in □ Yes
Weight: ____________ lbs □ No

Dermatology Associates of Central NJ & Freehold Skin Clinic & Cancer Center

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Dermatology Associates of Central NJ & Freehold Skin Clinic & Cancer Center

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Dermatology Associates of Central NJ &

Freehold Skin Clinic & Cancer Center

Why are you here today?__________________________________________________________________

Referring Physician: _______________________________________________________________________________

Referring Physician Phone #___(_______________)___________________-______________________________

Primary Care Doctor: ______________________________________________________________________________

Primary Care Phone #____(_______________)________________________-________________________________

Primary Care – MONTH/YEAR of last visit: _________________________ /__________________________

Have you been hospitalized since your last visit? YES or NO

If YES, please give reason for hospitalization: _________________________________________________

Pharmacy Name:_______________________________________ Phone #__________________________________

Street:____________________________________________________ Zip code: ________________________________

Date of Birth: ___________________________ Gender: Female or Male

Female: Date of Last Menstrual Cycle __________________________________________________

Past Medical History: (please CIRCLE all that apply):

Anxiety End Stage Renal Disease Leukemia

Skin Disease History: (please CIRCLE all that apply):

Acne Dry Skin Poison Ivy

Do you wear Sunscreen? Yes No

Do you tan in a tanning salon? Yes No

Do you have a history of Melanoma? Yes No

Do you have a family history of Melanoma? Yes No

Medications: (Please enter all current medications):

Allergies: (Please enter all allergies, including medication allergies):

All Patients Patients 12 and older

Do you have a history of Melanoma?

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Referring Physician Phone #_(___)_-______________________

Primary Care Phone #(_)-__________________

Primary Care – MONTH/YEAR of last visit: _ /__

Pharmacy Name:_____ Phone #

Street:____________________ Zip code: