Reason for your visit today:

Have you ever had skin cancer? Yes No

If yes, please explain:

Your Personal Medical History (ROS)

Yes No None
Yes No Anxiety Disorder
Yes No Arthritis
Yes No Asthma
Yes No Atrial Fibrillation
Yes No Benign Prostatic Hyperplasia
Yes No Cerebrovascular Accident
Yes No Chronic Obstructive Lung Disease
Yes No Coronary Arteriosclerosis
Yes No Depressive Disorder
Yes No Diabetes Mellitus
Yes No Elevated Blood Pressure
Yes No End Stage Renal Disease
Yes No Gastroesophageal Reflux Disease
Yes No Hearing Loss

Yes No Human Immunodeficiency Virus Infection
Yes No Hypercholesterolemia
Yes No Hyperthyroidism
Yes No Hypothyroidism
Yes No Inflammatory Disease of the Liver
Yes No Leukemia
Yes No Malignant Lymphoma
Yes No Malignant Tumor of Lung
Yes No Malignant Tumor of Breast
Yes No Malignant Tumor of Colon
Yes No Malignant Tumor of Prostate
Yes No Permanent Cardiac Pacemaker
Yes No Radiation Therapy Treatment Management
Yes No Transplantation of Bone Marrow
Yes No Other

Other

Skin Conditions:

Yes No None
Yes No Acne
Yes No Actinic Keratoses (pre-cancer)
Yes No Alopecia (Hair Loss)
Yes No Asteatosis Cutis (Dry Skin)
Yes No Basal Cell Carcinoma
Yes No Contact Dermatitis due to Poison Ivy
Yes No Dysplastic Nevus of Skin (pre-cancerous mole)
Yes No Eczema
Yes No H/O: Hay Fever

Yes No Herpes Simplex (Cold Sores)
Yes No Herpes Zoster (Shingles)
Yes No Malignant Melanoma
Yes No Pruritus of Scalp (Itching Scalp)
Yes No Psoriasis
Yes No Rosacea
Yes No Squamous Cell Carcinoma
Yes No Sunburn of Second Degree
Yes No Verruca (Wart)
Yes No Other

Other

Family History of Melanoma: Yes No
If Yes, which relative(s)

Rochester Dermatology Clinic participates with the following Pathology labs: Aurora, Beaumont & Crittenton.
If your insurance does not participate with any of the pathology labs listed above you will be responsible for the bill.

Do you need antibiotics for prophylaxis prior to procedures? Yes No

Any other major surgeries / procedures:

Habits: Tobacco use: Yes No Occasional