1. REVIEW OF SYSTEMS & MEDICATION SHEET
Patient::__________________________________________ DOB:_______________________
Have you ever had skin cancer?
What kind?
 I don’t know
Has your parent, sibling, grandparent or child ever had melanoma?
Have you ever had asthma?
Have you ever had seasonal allergies or hayfever?
Has anyone in your family had eczema?
Has anyone in your family had asthma, seasonal allergies or hayfever?
Do you now use or have you ever regularly used tobacco?
Have you ever had hepatitis?
Do you now have or have you ever had high blood pressure (hypertension)?
Do you have a pacemaker or defibrillator?
Do you have any joint replacements for which you need to take antibiotics for surgery?
Are you pregnant or breastfeeding?
Do you have trouble healing?
Do you tend to bleed excessively?
Do you have a tendency to form hypertrophic (enlarged) scars or keloids?
Do you get an allergic reaction to bandages, bandaids, or antibiotic ointments?
Do you have difficulty with oral antibiotics (e.g. nausea, diarrhea, yeast infections)?
Have you been having headaches and/or dizziness?
No Yes
 Basal Cell
 Squamous Cell
 Melanoma
 Other Type:
What other significant medical problems do you have (things like diabetes, heart disease, etc.)?  None
To what medications are you allergic?  None
Are you allergic to latex?  Yes  No
What medications do you currently take? (we only need names, not the dose or schedule)  None
How would you like to be addressed by the nurse when called in from the reception area ? ____________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________
Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________ Date::_________/_Patient Signature:___________________________/_Provider Reviewed:_________________