New Patient Forms · Bita Bagheri, MD

PERSONAL INFO

Name

First

Middle

Last

Address

City

State/Province

Zip/Postal

Preferred phone

Birthdate

Email

Gender

Employment

employed

unemployed

retired

student

Spouse/Parent's name

Emergency Contact name and number

How did you hear about us?

Friend

Doctor referral

Google

other

Who can we thank for referring you?

MEDICAL HISTORY

Primary Care Physician

First

Primary Care Physician's phone #

Primary Care Physician's fax #

Preferred Pharmacy Name

First

Preferred Pharmacy's phone #

Preferred Pharmacy's address

First

Preferred Pharmacy's fax #

Medical conditions

Prior history of melanoma?

yes

no

Melanoma location on body

Prior history of skin cancer?

yes

no

Skin cancer location on body

Prior history of Basal Cell Carcinoma?

yes

no

Basal Cell Carcinoma location on body

Prior history of Squamous Cell Carcinoma?

yes

no

Basal Squamous Carcinoma location on body

Prior history of unknown type skin cancer?

yes

no

Unknown type skin cancer location on body

Does your family have a history of malignant melanoma?

yes

no

If yes, who?

Have you ever had moles removed that were described as atypical?

yes

no

If yes, please describe location and how long ago were they removed?

Do you have a history of other dermatologic conditions? If yes, please list below

Prior Surgeries - please list all surgeries, including year

Medications - Please list all medications, dosage and frequency

I'm on blood thinners

yes

no

ALLERGIES

Allergies to medications or painkillers?

Food or environmental allergies?

Allergic to Adhesives?

yes

no

Allergic to Latex?

yes

no

Allergic to Lidocaine?

yes

no

LIFESTYLE

I use sunscreen regularly

yes

no

I use tanning beds regularly

yes

no

Smoking?

yes

no

Smoking frequency

Drinking?

yes

no

Drinking frequency

HOW CAN WE HELP?

Reason for your visit

How long have you had your symptoms?

Have you had this condition before? Is so, when?

What areas are affected?

Please describe your symptoms, if any.

Does anything make your symptoms better or worse?

Is this condition causing weight loss?

yes

no

don't know

Is this condition causing fever?

yes

no

Is this condition affecting your general health?

yes

no

Additional comments

Dr. Bita Bagheri's new patient forms

PERSONAL INFO

MEDICAL HISTORY

ALLERGIES

LIFESTYLE

HOW CAN WE HELP?