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 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
Skin Conditions:
Please check "Yes" or "No" to the following, as it pertains to you:
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
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
Alcohol use: Yes No Occasional
Have you had:
Flu 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:

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.


Reset Signature

Date / /