Patient:___________________________

Dermatology Specialists of St. Louis
Erin S. Gardner, MD FAAD FACMS
Patient: __________________________________________________________________________ Age: _____ Date: ________________
Select one: □ This consultation was requested by Dr. __________________ for ________________________ □ I was self-referred □ Existing patient
Please fill out this form completely! Use large check marks.
WHAT BRINGS YOU HERE? □ Check Skin Spots/Moles/Lesion □ Rash □ Skin Cancer □ Other _______________

1. What Location: □ Whole body □ Other _____________________________________________________________________________________

2. Duration of problem: ____ years / ____ months / ____ days OR □ Uncertain

3. Symptoms you are having: (Check those that apply.)
--If Lesion or Skin Cancer: □ None □ lesion growing □ non-healing □ bleeds □ changing color □ changing shape
--If Rash: □ None □ itching □ scaling □ crusting □ spreading □ tender □ painful

4. Previous / Current treatments (Lesion or Skin Cancer):
-For this/these lesion(s):
□ None □ Mohs surgery □ Excision □ Liquid nitrogen □ Curettage □ Blue Light / PDT □ Chemical peeling
Creams: □ 5-fluorouracil □ Imiquimod □ Other: ______________________ -For other lesion(s) you have had:
□ None □ Mohs surgery □ Excision □ Liquid nitrogen □ Curettage □ Blue Light / PDT □ Chemical peeling
Creams: □ 5-fluorouracil □ Imiquimod □ Other: ________________
5. Previous / Current treatments (Rash): (check all that apply, circle any that helped the rash)
□ None □ Phototherapy □ Sun avoidance □ Discontinuation treatment:______________________________________
Creams: □ Steroid cream □ Moisturizer □ Anesthetic □ Benadryl □ Anti-itch □ Antifungal □ other:_____________________ Oral medications: □ NSAIDs/Aspirin □ Benadryl □ Atarax □ Isotretinoin / Accutane □ Oral steroids □ other:_______________ -Previous biopsy or laboratory results:__________________________________________________________________________

6. Quality/Feeling of your Rash:
□ burning □ stinging □ stabbing □ twinging □ puffy-feeling □ ful -feeling □ tight-feeling □ progressive □ worsening
7. Timing/Context for your Rash: □ NO particular factors influence my rash OR
□ The following factors have made my rash better or worse (select only those that apply):
better / worse
better / worse
□ □ □ Started after taking/using _______________ □ □ □ Following Trauma to the Site ============================================================================================================================================

Medications you take: □ None □ List or attach list ________________________________________________________________________
______________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Al ergies to Medications: □ None known □ List:________________________________________________________________________

Tell us about your Family History:
-Family history of skin cancer: □ None □ List type & relation: __________________________________________________________________
-Family history of other skin problems: □ None □ List: _______________________________________________________________________

Tel us about your Social/Personal History:
Lifetime Occupational / Recreational Sun Exposure: □ light □ moderate □ heavy Alcohol Use: □ none □ social □ regular □ former
Indoor Tanning: □ never □ occasional prior □ occasional current □ regular prior □ regular current ___drinks/day ___drinks/week ___drinks/month
Living Situation: □ alone □ home with family / roommate □ assisted living
Smoking: □ never □ current: ____ packs/day □ former

Tel us about your Skin/Dermatologic History: (check all that apply)
-History of skin cancer: □ None □ List type & site: __________________________________________________________________________
-History of other skin diseases: □ None □ List: ____________________________________________________________________________
□ History of keloids □ History of poor wound healing What other Dermatologic services or products interest you?
□ Moisturizers/emollients for sensitive skin □ Topical retinoids for fine wrinkling □ Botox Dermatology Specialists of St. Louis
Erin S. Gardner, MD FAAD FACMS
►Indicate below whether you have a history of any of the following conditions:
Neurologic:
Pacemaker
Neurologic implant / stimulators □ □
Defibril ator
Endocrine:
Hematologic / Lymphatic:
Infections History:
Musculoskeletal:
Metal implants / artificial joints □ □
Oncologic:
Allergic / Immunologic:
Gastrointestinal:
Genitourinary:
--specify: □ A □ B □ C □ D □ E Gynecologic
Psychiatric:
Ear/Nose/Throat/Mouth:
Sterilization – tubal ligation/vasectomy □ □ Any other significant diseases / conditions: ________________________________________________________________________________
Any other relevant surgical procedures: ___________________________________________________________________________________
_______________________________________________________

Source: http://dermsurgerystl.com/Initial-History-Form.pdf