BCD New Patient Intake Form Revised 09.08.2021mn

New Patient Intake Form

Welcome To Bold City Dermatology! Please fill out all fields of the form.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
PERSONAL INFORMATION:
Name

First NameLast Name
Marital Status
SSN
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Address
Apt/Unit
City
State
Zip
Preferred Telephone #
Format: (000) 000-0000.
Please indicate your PREFERRED telephone number type:

Other
Alternative Telephone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Please indicate your ALTERNATIVE telephone number type:

Other
Email Address
example@example.com
Preferred Contact Method ( Select one)
Is it OK for us to leave a detailed message?
IF it is okay for us to leave a detailed message, which phone number is preferred?

Other
Race ( Please select)

Other
Retired
Language: Select all that apply

Other
Employer
Ethnicity ( Please select )
Occupation
Industry
Emergency Contact and Authorization to share Medical Information:
Name
Relationship
Phone #
Format: (000) 000-0000.
You have my permission to share medical results/information with the above person:
Any other authorized person Name
Relationship
Phone
Format: (000) 000-0000.
Primary Care Doctor
Referring Doctor
Preferred Pharmacy: (Include city and street or street intersection):
Name
City/Street
Phone (if known)
Format: (000) 000-0000.
Height
Weight
PAST MEDICAL HISTORY
Past Medical History ( Select all that Apply)

Other
PAST SURGERIES: (Select all that apply and indicate year, if known)
Have you had any of the following skin conditions ( select all that apply)

Other
Do you use sunscreen
If yes, indicate the SPF used
Do you tan in a tanning salon?
Please indicate if you have a family history of the following:

Notate which relative(s) have had the following condition
Melanoma
Type Yes / No
If yes, which relative(s)?
Other Skin Cancers?
Type Yes / No and Indicate type of cancer or condition
If yes, which relative(s)?
Other Diseases?
If yes, which relative(s)?
Medication Allergies/Reaction: (Please indication allergies to medications and your reaction)
Please list all drug allergies in the space below
Alcohol and Smoking History
Male: How many times in the last year did you have 5 or more drinks in a day?
Female: How many times in the last year did you have 4 or more drinks in one day?
How many packs/day
What is your smoking status?
If current Smoker: What is the total Yrs. smoking?
Medications: (Please list (name/dosage/route/frequency) or provide us your medication list)

Medication History

Rows	Name of Medication	Dosage	Route	Frequency
1. Medication
2. Medication
3. Medication
4. Medication
5. Medication
6. Medication
7. Medication
8. Medication
9. Medication

Do any of the following apply to you:
Do you have any of the following (Please select all that apply):
Do any of the following apply to you: Select all that apply

Other
Would you allow a medical student and or resident physician to observe during your visit?
Have ever received a pneumonia vaccination?
NO, if not why?
Have you received the Flu immunization in the last year?
NO, if not why?
Do you have a surrogate decision maker?
Surrogate Decision Maker Name
Surrogate Decision Maker Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Primary Ins. Policy
Insurance Policy No.
Group Number
Insurance Phone Number
Format: (000) 000-0000.
Subscriber Name

First NameLast Name
Subscriber DOB
Subscribers Relationship to Patient
Secondary Insurance Information
Name of Secondary Ins. Policy
Insurance Policy No.
Group Number
Insurance Phone Number
Format: (000) 000-0000.
Subsriber Name
Subscriber DOB
Subscribers Relationship to Patient

Past Surgeries :

Rows	Yes	If Yes, What year	Left / right /both
Appendix Removal
Bladder ( Cystectomy
Breast Biopsy
Lumpectomy
Mastectomy
Colon resection
Colectomy
Gallbladder removal
Heart : Valve replacement
Heart: Coronary Artery Bypass
Heart Transplant
Mechanical Valve Replacement
Heart Cath / Stents
Joint Replacement: Hip
Joint Replacement: Knee
Kidney: Biopsy
Kidney Stone Removal
Kidney Transplant
Kidney Removal
Liver Removal
Liver Transplant
Liver Shunt
Removal of ovaries: Endometriosis
Removal of ovaries: Cancer
Ovarian Ovarian Cyst removal
Tubal ligation
Prostate Cancer
Prostate Removal
Pancreas removal
TURP
Abdominoperineal resection
Lower anterior resection
Basal cell carcinoma Removal
Skin Biopsy
Squamous cell carcinoma removal
Melanoma Removal
Removal of spleen
Testical Removal
Uterus Removal
Uterine Cancer
Cervical Cancer

Should be Empty:

New Patient Intake Form

PERSONAL INFORMATION:

Alcohol and Smoking History