Health History Information Form

Date: / /
DOB: / / M F
(Type of work, student or retired)
Best Contact #
Reason for your visit today:
Have you ever had skin cancer? Yes No
If yes, please explain:
Your Personal Medical History (ROS)
Please check “Yes” or “No” to the following, as it pertains to you:
Yes No Anxiety
Yes No Arthritis
Yes No Asthma
Yes No Atrial Fibrillation
Yes No BPH (Enlarged Prostate)
Yes No Bone Marrow Transplantation
Yes No Breast Cancer
Yes No Colon Cancer
Yes No COPD (Lung Disease)
Yes No Coronary Artery Disease
Yes No Depression
Yes No Diabetes
Yes No End Stage Renal Disease
Yes No GERD (Acid Reflux)
Yes No Hearing Loss
Yes No Hepatitis
Yes No Hypertension (High Blood Pressure)
Yes No Hypercholesterolemia
Yes No Hyperthyroidism
Yes No Hypothyroidism
Yes No Leukemia
Yes No Lung Cancer
Yes No Lymphoma
Yes No Pacemaker
Yes No Prostate Cancer
Yes No Radiation Treatment
Yes No Seizures
Yes No Stroke
Yes No Valve Replacement
Skin Disease History:
Please check "Yes" or "No" to the following, as it pertains to you:
Yes No Acne
Yes No Actinic Keratoses
Yes No Alopecia (Hair Loss)
Yes No Basal Cell Skin Cancer
Yes No Blistering Sunburns
Yes No Dry Skin
Yes No Eczema
Yes No Flaking or Itchy Scalp
Yes No Hay Fever / Allergies
Yes No Herpes Simplex (Cold Sores)
Yes No Melanoma
Yes No Poison Ivy
Yes No Psoriasis
Yes No Rosacea
Yes No Shingles
Yes No Squamous Cell Skin Cancer
Yes No Warts
Family History of Melanoma: Yes No
If Yes, which relative(s)
Rochester Dermatology Clinic participates with the following Pathology labs: Aurora, Inform Diagnostics, 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 serious illnesses or major surgeries / procedures:
Habits: Tobacco use: Yes No Occasional
Alcohol use: Yes No Occasional
Have you had:
Flu Vaccination Yes No
Shingles Vaccination Yes No

Pneumonia Vaccination (65 or older) Yes No
Do you have an: Advance Care Plan (Living Will) Yes No
If yes, list surrogate decision maker
For Females:
Are you pregnant? Yes No

Planning a pregnancy? Yes No

Nursing? Yes No
Medications: RX and Over-The-Counter:
Here are the medications I am currently taking and their dosages (if known):

Are you taking a blood thinner? (Aspirin / Coumadin / Plavix / Fish Oil) Yes No
Please list any allergies you have to medications / tape adhesive / Latex? Please Specify reaction:
Preferred Pharmacy:


Location (address, state, zip)


All the above is stated to the best of my knowledge.

[ We will obtain signature at your appointment. ]
Date / /