Mohs Pre-Operative Paperwork

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Past Medical History

Anxiety?

YesNo
Year

Depression?

YesNo
Year

Diabetes?

YesNo
Year

Liver disease?

YesNo
Year

Hepatitis?

YesNo
Year

Fainting?

YesNo
Year

Irregular heart rhythm?

YesNo
Year

Atrial Fibrillation?

YesNo
Year

Chest Pain?

YesNo
Year

Heart Attack?

YesNo
Year

High blood pressure?

YesNo
Year

Bypass Surgery?

YesNo
Year

Organ Transplant?

YesNo
Year

Blood Clots?

YesNo
Year

Pacemaker?

YesNo
Year

Defibrillator?

YesNo
Year

Heart Valve Replacement?

YesNo
Year

Stroke?

YesNo
Year

Current Weight: Current Height:
Do you have artificial joints, valves?
YesNo
Do you take antibiotics before surgical procedures?
YesNo
Are you immunosuppressed?
YesNo
Have you had or have you been exposed to HIV (AIDS)?
YesNo
Have you ever been diagnosed with Chronic Lymphocytic Leukemia?
YesNo
When
Do you drink alcohol?
YesNo
If Yes, drinks per day and what type
Do you use IV drugs?
YesNo
If Yes, what?

How much?
Do you currently smoke?
YesNo
Have you tried to quit?
YesNoNot Applicable
Have you ever had dental anesthesia (Novocain)?
YesNo
Any bad reaction?
YesNo
Do you bleed easily?
YesNo
Do you take any OTC medications that thin your blood (Aspirin, Aleve, Ibuprofen) or supplements that thin your blood (fish oil, garlic, vitamin E, Ginko Biloba)?
YesNo
Do you take any medications that thin your blood (Coumadin, Plavix, Xarelto, Eliquis or another
prescribed blood thinner)?
YesNo
Has anyone in your family had skin cancer?
YesNo
Relation?
Do you have a family history of other cancers?
YesNo
Relation?

Medications

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Name of medication/supplement

Dose

Frequency

Are you allergic to any medications?

YesNo
If Yes, please list below:

(Women) Are you pregnant or nursing?
YesNo
Due Date:
What is your occupation?

What are your hobbies?

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