Patient Health Questionnaire

Employment

If Working, Job title and duties

Exact location of lesion

Duration of Lesion

< 1 Yr 1-5 Yrs > 5 Yrs

Previous treatment other than the biopsy

List all medications/drugs/vitamins/prescription creams you are currently using (including nonJprescription medications like Aspirin, Ibuprofen). It is not necessary to provide dosages. Write None if not taking any medication.

Are you on Coumadin or Warfarin

No Yes

If Yes, Provide latest INR

Do you have or have you ever had any of the following conditions?

Previous skin cancer

No Yes

Which type i.e. Basal cell, Squamous cell, Melanoma

Other cancer (e.g. lymphoma or leukemia)

No Yes

Previous radiation therapy

No Yes

Fear of needles

No Yes

Defibrillator

No Yes

Heart valve replacement

No Yes

Heart infection

No Yes

Heart blockage

No Yes

Lung / breathing problems requiring oxygen therapy

No Yes

Liver disease (e.g. hepatitis)

No Yes

Kidney disease (e.g. dialysis)

No Yes

High blood pressure

No Yes

Organ transplant

No Yes

Joint replacement / infection (e.g. hip, knee)

No Yes

Difficulty lying on your back / wheelchair / walker

No Yes

Allergies (e.g. Penicillin, Clindamycin, Lidocaine, Xylocaine, Tylenol, Codeine, Latex, Band-Aids)

No Yes

Allergy tested / EpiPen

Infection (e.g. HIV, Hepatitis, MRSA, VRE)

No Yes

Patient Health Questionnaire

Emergency Contact

Receive Our Newsletter