Mohs Pre-Operative Paperwork

Ali Rkein, MD

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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?

    Telemedicine appointments now available! Contact us today to find out how Desert Sky Dermatology can help you with many of your skin care needs!