Medical Intake Form

Please complete the necessary patient demographics below

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Please upload 3 photos of your concern below.

Directions:
 
1. For imaging one specific area on the body, we recommend a distance photo to see the area involved, a near photo, and a very close photo. Please ensure each image is in focus.
 
2. For imaging a widespread rash, please upload three photos to show the entirety of involvement from 3 different angles.
 
Tips for taking high quality images:
 
1. Use a solid background. Avoid backgrounds that may be distracting (reflective, busy, cluttered).
 
2. Use your phone's back camera. Ask someone to help you if needed. 
 
3. Ensure there is adequate lighting and turn off your flash.
 
4. Check your photos for focus. A very sharp image is critical. 



Please check appropriate box (Y/N) as each applies to your CURRENT OR PAST MEDICAL HISTORY

Artificial heart valve/infection *
Artificial join (past 2 years) *
Cold sores/herpes *
Hepatitis *
HIV/AIDS *
Organ transplant *
Pacemaker/Defibrillator *
Staph bacterial infection *
MRSA Infection *
Vasovagal reaction (fainting) *
Premedication prior to procedures *
Accutane use in the last 6 months *
Diabetes *
High blood pressure *
Dementia *
Autoimmune condition *
Cancer (other than skin) *
Radiation treatment *
Surgical Procedures (within the past two years) *
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History of Skin Cancer

Have you had MELANOMA SKIN CANCER? *
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Have you had BASAL CELL CARCINOMA? *
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Have you had SQUAMOUS CELL CARCINOMA? *
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Has anyone in your FAMILY HAD MELANOMA? *
Do you wear Sunscreen *

Are You ALLERGIC to:

Adhesive *
Epinephrine *
Lidocaine *
Antibiotic ointment *
Latex *
Allergies to Medication *

Social History

Alcohol use *
Cigarette smoking *

REVIEW OF SYSTEMS

Pregnant or planning *
Currently breastfeeding *
Recent biologic medication *
Recent chemotherapy *
Problems with bleeding *
Immunosuppression *
Abnormal blood counts *
Abnormal scarring *
Enlarged lymph nodes *
Fever or chills *
Recent Illness *
Please check the following vaccinations you have received *
Patient Signature *
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