Anxiety Arthritis Asthma Atrial Fibrillation Bone Marrow Transplantation BPH Breast Cancer Colon Cancer Coronary Artery Disease Depression Diabetes End Stage Renal Disease Other (Enter Below) Hearing Loss Hepatitis Hypertension HIV/AIDS Hypercholesterolemia Hypothyroidism Leukemia Lung Cancer Lymphoma Prostrate Cancer Radiation Treatment Seizures Stroke Past Medical History Please select any of the following conditions that you currently have: Physician List: Please list the name and location of your physicians: 1. Primary care physician: 2. Other: 3. Other: 4. Other: Name: Birthdate:

Appedix (Appendectomy) Bladder (Cystectomy) Breast: mastectomy (right breast) Breast: mastectomy (left breast) Breast: mastectomy (both breasts) Breast: lumpectomy (right breast) Breast: lumpectomy (left breast) Breast: lumpectomy (both breasts) Breast: breast biopsy Breast: breast reduction Breast: breast implants Colon (colectomy): colon cancer resection Colon (colectomy): diverticulitis Colon (colectomy): inflam. bowel disease Gall bladder (cholecystectomy) Heart: coronary bypass surgery Heart: coronary stent placement Heart: mechanical valve Heart: biological valve Heart: heart transplant Joint replacement: knee right Joint replacement: knee left Other surgeries (enter below) Joint replacement: knee both Joint replacement: hip right Joint replacement: hip left Joint replacement: hip both Kidney: kidney biopsy Kidney: nephrectomy Kidney: kidney stone removal Kidney: kidney transplant Ovaries (oophorectomy): endometriosis Ovaries (oophorectomy): ovarian cyst Ovaries (oophorectomy): ovarian cancer Prostate (prostatectomy): prostate cancer Prostate: prostate biopsy Prostate (prostatectomy): TURP Skin: skin biopsy Skin: basal cell carcinoma Skin: squamous cell carcinoma Skin: melanoma Spleen (splenectomy) Testicles (orchiectomy) Uterus (hysterectomy): fibroids Uterus (hysterectomy): uterine cancer Past Surgeries Please select any of the following surgeries that you have had:

Acne Actinic Keratoes Asthma Basal cell skin cancer Blistering sunburns Dry skin Eczema Other skin conditions: Flaking or itchy scalp Hay fever/allergies Melanoma Poison ivy Precancerous moles Psoriasis Squamous cell skin cancer Lung Cancer Skin Disease History Have you had any of the following conditions? Do you wear sunscreen? Yes No Do you tan in a tanning salon? Yes No If yes what SPF? ______ Do you have a family history of melanoma? Yes No If yes which relative ? ________________

Medications: Allergies: Please list any medication allergies you have and what your reaction was. 1. Drug Reaction