Patient: Date:

1. Allergies to medications/numbing medications:
   
2. Medications currently being taken, including birth control pills:
   
3. Do you now, or have you ever in the past had: (mark only if your answer is Yes)
   high blood pressure diabetes (sugar) - if yes, you do you take insulin dosage
   artificial joints heart trouble pace maker
4. Please list any major illness/surgeries that you have or have had (please give dates of surgeries/onset of illness)
   
5. Have you ever been treated for skin cancer? When
   What type
6. Do you have a family history of skin cancer? Who
   What type
7. When you are exposed to the sun for extended periods of time do you: Burn Burn/Tan Tan
   Women Only
   If applicable, could you be pregnant? Are you trying to become pregnant?
   Are you nursing?
   

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   Briefly list why you are here to see the doctor today: