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Mohs pre-op health info

Greater Washington Dermatology
2401 Research Boulevard, #260, Rockville, MD 20850, 301-990-6565
KELLEY PAGLIAI REDBORD, M.D.
PREOPERATIVE HEALTH INFORMATION FORM
Patient Name: ____________________________________________
Date: ____________________________
Gender: M F Age ________ Date of birth: ___________ Marital status S M D W Primary care provider:___________________________________________________________________________ Location(s) of problem(s) for which you are being seen _______________________________________________ How long has this problem been present? ___________________________________________________________ Have you had a biopsy of this site? No Yes Other than a biopsy, have you previously had treatment at this site? No Yes If yes, what type of treatment? ________________________________________________________ ____________________________________ Mohs surgery patients: I have read the instructions in the Mohs Surgery Patient Handbook No Yes

Past and Active Medical Problems: ______________________________________________________________
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Previous major surgeries and dates (year): ________________________________________________________
____________________________________________________________________________________________ Medications (Please list ALL PRESCRIPTION and NON-PRESCRIPTION medications that you take including aspirin,
over-the-counter pills, vitamins and herbal remedies.) __________________________________________________
____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Allergies to Medications None Yes (List medication and how you react):, _________________________
_____________________________________________________________________________ Have you had any problems with local anesthesia or epinephrine? If yes, what was the reaction?________________________________ Have you had difficulty with wound healing, abnormal scarring or keloids? Have you been advised to take antibiotics before routine dental work or surgery? No Have you had bacterial endocarditis (infection of a heart valve)? If yes, joint(s) and date(s) of surgery_________________________________________ Have you ever had bleeding problems after dental work or surgery? Do you have a tendency to bleed or bruise easily? Female patients:
Date of last menstrual period: ________________________________ Skin cancer patients: Have you had skin cancer before?

Check all that apply regarding your health:
Check all that apply:
SOCIAL AND FAMILY HISTORY
Occupation: ______________________________________________________________________________________
Alcohol use:
Do you have someone who can accompany you on the day of surgery? Do you have someone who can help you with changing bandages?
FOR SKIN CANCER PATIENTS:
Have you had an organ transplantation?
Have you had X-ray treatment for a skin disease in the past? Do you have a history of blistering sunburns in childhood or as an adult? Do you have an outdoor occupation or hobbies?
CONTACT INFORMATION
Pharmacy name, street, and city: ______________________________________________________________________
Which phone number(s) are best to reach you?
Home_______________________May we leave a message at this number regarding your healthcare? No Yes Cell________________________ May we leave a message at this number regarding your healthcare? No Yes Work_______________________ May we leave a message at this number regarding your healthcare? No Yes
For office use only: I have reviewed the patient’s health information with the patient and documented any changes:
Date: _________ Asst: _______ MD:____________ Date: _________ Asst: _______ MD:____________ Date: _________ Asst: _______ MD:____________ Date: _________ Asst: _______ MD:____________ Date: _________ Asst: _______ MD:____________

Source: http://www.skinmatters.net/forms/MOHS_Pre-Op_Info.pdf

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