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Past Medical/Surgical/Family History
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Past Medical History ( select all that apply)
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Past Medical History also includes?
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Past Surgical History ( select all that apply)
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Past Surgical History also includes?
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Family History of First Degree Relatives ( select all that apply)
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Family History also includes?
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Skin Disease History
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Skin Disease History ( Select all that apply)
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Skin Disease History also includes?
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Do you wear sunscreen?
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If yes, what SPF?
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Family History of Melanoma?
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If yes, which relatives?
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Family history of other types of Skin Cancer?
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If yes, which relatives?
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Medications
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Please list all Medications ( Name, dose, frequency)
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Allergies
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Please list all known allergies ( if no allergies write "None")
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Alerts
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Please select all that apply to you
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Other Info
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Where did you find us?
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Which specialists do you see?
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Who referred you?
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Do you use online scheduling?
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Want access to online portal?
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Anything special we need to know
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