Have you ever had skin cancer?

1
Patient_________________________________________
_ DOB_______________________
Have you ever had skin cancer?
What kind?
? I dont know Has your parent,
sibling, grandparent or child ever had
melanoma? ? I dont know Have you ever had
asthma? ? I dont know Have you ever had seasonal
allergies or hayfever? ? I dont know Has anyone
in your family had eczema? ? I dont know Has
anyone in your family had asthma, seasonal
allergies or hayfever? ? I dont know Do you now
use or have you ever regularly used
tobacco? Have you ever had hepatitis? ? I dont
know Do you now have or have you ever had high
blood pressure (hypertension)? ? I dont know 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 No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes No Yes No Yes No
Yes No Yes 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 1. 2. 3.
What medications do you currently take? (we only
need names, not the dose or schedule) ?
None 1. 2. 3.
How would you like to be addressed by the nurse
when called in from the reception area ?
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