John Wayne Cancer Center Dermatological Center for Skin Health Delphine J. Lee, MD, PhD, FAAD 2121 Santa Monica Boulevard, Garden Level Santa Monica, CA 90404 310-449-5265 Office – 310-449-5273 Fax Medical Questionnaire

Date:

Name:

Gender:

Male

Female Age:

Last First Middle Birth-date: Birth Place: Mother’s Birth Name: Social Security Number: Driver’s License #: Marital Status: Single Married ~ Spouse’s Name Married how long? Divorced Separated Widowed Language Spoken: Interpreter Required? Yes No Home Address: City: State: Zip-code: Phone: Fax: Employer: Address: City:

State:

Zip-code:

Occupation: Phone: Fax: Relationship:

Emergency Contact: (Not living in the same household) Address: City: Phone:

State:

Zip-code:

-

State: Fax:

Zip-code:

-

Fax:

Local Telephone Number: (Relative, Friend or Hotel) 1. Primary Care Physician: Specialty: Address: City: Phone: 2. Referring Physician (if other than #1): Specialty: Address: City: Phone:

State: Fax:

Zip-code:

-

3. Other Physician: Specialty: Address: City: Phone:

State: Fax:

Zip-code:

-

Revised 8/7/2014   

Page 1 of 10  

Patient Name: ALLERGIES: Category

Yes

No

Do Not Know

List Specific item (for example. sulfa, eggs, dust mites)

What happens (for example, rash, swelling, itchy eyes)?

Drugs Food Environmental

PRESENT ILLNESS: Please describe in your own words the date of onset of your illness, symptoms & treatment.

How long have you had symptoms? Are they constant or do they come and go? What makes it worse?

Has anything made it better?

Revised 8/7/2014   

Page 2 of 10  

Patient Name: Please indicate if you currently are experiencing any of the following. If you are not sure, please mark “Do Not Know” and we will be happy to assist you during your scheduled visit. GENERAL Condition 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

YES

NO

Do Not Know

YES

NO

Do Not Know

YES

NO

Do Not Know

Fever/Chills Swollen or enlarged (lymph) glands Weight Changes (loss or gain) Night sweats (soaking the sheets) Fatigue Insomnia Loss of appetite Cancer Infectious disease Pain

SKIN Condition 1. 2. 3. 4.

New or Changing moles Birthmarks New rashes Sensitivity to the sun

HEAD, EYES, EARS, NOSE THROAT - (HEENT) Condition 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Headaches Dizziness Fainting spells Vision problems Double or blurred vision Problems with hearing Sinus trouble Nose bleeding Sore tongue Bleeding gums Unusual trouble with teeth Recent cold or sore throat Itchy eyes (Allergies) Itchy nose (Allergies) Dry eyes

Revised 8/7/2014   

Page 3 of 10  

Patient Name: ENDOCRINE

1. 2. 3. 4. 5. 6.

Condition

YES

NO

Do Not Know

Condition

YES

NO

Do Not Know

YES

NO

Do Not Know

YES

NO

Do Not Know

Thyroid problems Heat or cold intolerance Changes in hair or nails Changes in skin texture Bone disorders Diabetes

HEART

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Heart problems Bruise easily or bleed easily Bleeding problems High blood pressure Pressure in chest Undue shortness in breath (day or night) Ankle Swelling Edema Pain in legs while walking Have you ever had a blood transfusion Implanted device (Shunt, pump, pacemaker)

PULMONARY Condition 1. 2. 3. 4. 5. 6. 7.

Chronic cough Coughed up blood Soaking sweats Exposure to TB History of a positive TB test (PPD) Asthma Lung disease

GASTROINTESTINAL Condition 1. 2.

Abdominal pain Difficulty swallowing

Revised 8/7/2014   

Page 4 of 10  

Patient Name: 3. 4. 5. 6. 7. 8. 9. 10. 11.

Nausea or vomiting Frequent bowel movements Constipation Recent change in bowel movements Black bowel movements Blood in stools Jaundice History of hepatitis (liver disease) History of inflammatory bowel disease

GENITOURINARY URINARY Condition 1. 2. 3.

NO

Do Not Know

YES

NO

Do Not Know

YES

NO

Do Not Know

Kidney problems Blood in urine Testicular pain

MUSCULOSKELETAL/IMMUNE Condition 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

YES

Joint pain Back or bone pain Numbness or tingling of hands or feet Muscle pain or weakness, sore muscles Muscle spasms History of autoimmune disease Abnormal antibody tests Immune problems Color changes in fingers/toes (white, blue or red) Blood disease

NEUROLOGIC Condition 1. 2. 3. 4. 5. 6. 7. 8. 9.

Excessive worry Excessive depression Nervous disorders Slowed thinking, decreased concentration or decreased memory (out of ordinary) Seizures Tremors Strokes Trans Ischemic Attack (TIA) Changes in your vision

Revised 8/7/2014   

Page 5 of 10  

Patient Name: 10. 11. 12. 13. 14. 16. 17. 18.

Problems with bowel Bladder control Unsteady walking Loss of balance Headaches History of anesthesia problems Mental Illness Family history of anesthesia problems

HABITS 1. Alcohol intake: Yes No Indicate next to each the amount of drinks and Frequency – i.e. Daily, Weekly or Monthly. 1. Beer 2. Wine 3. Whiskey 4. Other 2. Smoking: Cigarettes packs 3. Intravenous Drug use? Yes No 4. Other Drug use? (such as freebase cocaine) Yes No 5. Exercise If yes, type and frequency? PAST SURGERIES (Operations): Please list in chronological order DATE TYPE OF OPERATION

OTHER HOSPITALIZATIONS: Please list in chronological order DATE

REASON FOR SURGERY

TYPE

OTHER MEDICAL PROBLEMS:

Revised 8/7/2014   

Page 6 of 10  

HOSPITAL

DOCTOR

HOSPITAL

DOCTOR

Patient Name: Please list any medications/herbs/supplements you are taking, date that you started and the date you discontinued (if applicable). Pain Pills: Tranquilizers: Sleeping Pills:

Antibiotics (recently): High blood pressure medicine/water pills: Medicine for cholesterol control: Over the counter/non-prescription drugs/nutritional supplements (i.e. Aspirin, Tylenol, Motrin, Aleve, Vitamins, Diet Pills, herbs, etc.):

Other medications: FAMILY HISTORY: Relation Age State of Health If deceased – Cause of Death Father Mother Spouse Brothers

Sisters

Children

Revised 8/7/2014   

Page 7 of 10  

Age at Death

Patient Name: Have any of your blood relatives, husband, wife or children had any of the following? YES NO (CHECK EACH ITEM) RELATION(S) Tuberculosis Diabetes Cancer (Melanoma, Basal cell, Squamous cells, Merkel or other) Autoimmune disease (Lupus, Dermatomyositis, Vitiligo, Pemphigus, Pemphigoid, Scleroderma) Unusual moles (Atypical Nevus Syndrome, Giant Congenital Nevus) Kidney Disease Asthma, Hay Fever, Other Allergy Chronic Arthritis (Rheumatism) Multiple Sclerosis or Guillan Barre Syndreom Nervous Or Mental Disorder Any Other Illness (please specify):

FITZPATRICK SKIN-TYPE - Please circle which describes you best. Genetic Disposition Score 0 1 2 3 Light blue, Blue, Grey or Blue Dark Brown What is the Grey, Green Green color of your eyes? Sandy Red Blond Dark Chestnut/ What is the Brown Dark natural color Blond of your hair? Reddish Very Pale Pale with Light What is the Beige Brown color of your tint skin (non sunexposed areas)? Many Several Few Incidental Do you have freckles on unexposed areas?

Revised 8/7/2014   

Page 8 of 10  

4 Brownish Black Black

Dark Brown

none

Patient Name:

Reaction to Sun Exposure - Please circle which describes you best. Score 0 1 2 3 Blistering Burns Rare What happens Painful redness, followed by sometimes burns when you peeling followed by stay in the sun blistering, peeling peeling too long? To what degree do you turn brown? Do you turn brown within several hours after sun exposure? How does your face react to the sun?

Hardly or not at all Never

Light color tan

Reasonable tan Tan very easy

Seldom

Sometimes

Often

Turn dark brown quickly Always

Very sensitive

Sensitive

Normal

Very resistant

Never had a problem

Classification Scale – Please circle which skin type fits you best. Skin Type I II III IV Skin Color White; White; Brown Cream

Characteristics

very fair; red or blond hair; blue eyes; freckles

fair; red or blond hair; blue, hazel, or green eyes

white; fair with any eye or hair color; very common

Always burns, never tans

Usually burns, tans with difficulty

Sometimes mild burn, gradually tans

RECENT TRAVEL: Dates

Revised 8/7/2014   

4 Never had burns

Location

Page 9 of 10  

Rarely burns, tans with ease

V

VI

Dark Brown

Black

Very rarely Never burns, tans burns, very easily tans very easily Unusual exposures

Patient Name: Certain diseases are more common in specific genetic backgrounds. Please indicate your ethnicity: Caucasian Asian Black or African American Hispanic/Latino Non-African Black Other: ______________ American Indian or Alaska Native

Revised 8/7/2014   

Page 10 of 10