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5889 Greenwood Plaza Blvd, Suite 250
Greenwood Village, CO 80111

P: (303) 222-9559
F: (303) 222-9557

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Contact Us

Record Release Form

Referring Providers

Medical History Intake Form

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- Step 1 of 7

Patients Information

Patient Name *

First

Last

Date of Birth *

Primary Care Physician:

How did you hear about us?

Reason for today’s visit

Medications

Do you have any medication allergies?

List prescription medications you take:

List over-the-counter medications you take:

Medical History

Do you have any allergies to the following?

Latex
Lidocaine
Adhesive/band-aids
Iodine
Shellfish

If so, please mark the appropriate boxes

Mark any skin conditions you have a history of or currently have:

Psoriasis
Autoimmune disease
Eczema
Hives
Hay fever
Asthma
Atypical moles
Actinic Keratoses
Basal cell cancer
Squamous cell cancer
Melanoma
Arthritis

Do you have any of these?

Pacemaker
Defibrillator
Joint implants
Heart valve disease
Solid organ transplant
Bone marrow transplant
HIV infection
History of hepatitis
Bleeding disorder
Keloidal scarring
Take blood thinners
History of blood clots
Heart murmur

If so, please mark the appropriate boxes

List other skin conditions not mentioned above:

Do you need pre-medication antibiotics for dental work or surgery?

Yes
No

you relatives day?

Medical Conditions

Do you have any of these disorders?

Eye disease
Kidney disease
Liver disease
Coronary artery disease
High blood pressure
Thyroid disorder
Diabetes Type 1
Diabetes Type 2
Seizures
High cholesterol
Stroke

If so, please mark the appropriate boxes:

List other medical conditions not mentioned above:

List any surgeries requiring general anesthesia:

Mark any symptoms that apply to you:

Unexplained fever
Drenching night sweats
Unexplained weight change
Fatigue
Joint pain
Chronic cough
Chest tightness
Chest pain
Headaches
Varicose veins
Abdominal pain
Diarrhea
Irregular heart beat
Lower extremity swelling
Depression

Other Symptoms:

When you are exposed to the sun do you:

always burn; extremely sun sensitive?
burn easily; then tan a little?
tan slowly; sometimes burn?
always tan; burn a little?
tan well; rarely burn?
never burn?

Do you have photosensitivity

Yes
No

(sensation of burning on your skin when exposed to sunlight)?

Do you have any first-degree relatives with a history of melanoma?

Yes
No

(sensation of burning on your skin when exposed to sunlight)?

Do any first-degree relatives have skin conditions?

Yes
No

If so, what kind?

Do any first-degree relatives have auto-immune conditions?

Yes
No

(ex: lupus, rheumatoid arthritis, thyroid disorders)

What kind?

Other

Do you wear sunscreen on your face daily?

Yes
No

Have you ever used a tanning bed? *

Yes
No

If so, how many times have you tanned indoors in your lifetime?

Do you still use tanning beds? *

Yes
No

Have you ever had a blistering or painful sunburn? *

Yes
No

What is/was your occupation? *

What are your hobbies?

Do you drink alcohol? *

Yes
No

If yes, how many drinks per day?

Do you smoke cigarettes/vape? *

Yes
No

If yes, how many times per day?

Do you smoke or ingest pot? *

Yes
No

Do you use illicit drugs? *

Yes
No

Women only

Are you on any form of oral, injectable or implantable contraceptives?

Yes
No

Are you pregnant or trying to become pregnant?

Yes
No

Pharmacy Information

Farmacy Name *

Zip code *

Patient Signature

Signature

Clear Signature

Denver Tech Dermatology Associates

Scala Office Building

5889 Greenwood Plaza Blvd, Suite 250
Greenwood Village, CO 80111

(303) 222-9559
(303) 222-9557

@denvertechderm

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