CAUTERY
01
Do you have a pacemaker, defibrillator, neurostimulator, cochlear implant, or other electronic implant?
ANTIBIOTICS
02
What is your preferred pharmacy?
03
Have you been instructed to take pre-dental antibiotics? Are you immunosuppressed (chemotherapy in the past six months, transplant, CLL)? Artificial joint less than two years old? Artificial heart valve?
04
Mohs site on nose, ears, lips, groin, or lower legs?
05
Are you allergic to any antibiotic (such as penicillins, Amoxicillin, Keflex, or Clindamycin)?
06
Please list any drug allergies, including antibiotic / pain / latex allergy. (Write NKDA if no allergies; don't leave blank)
BLEEDING
07
Do you take Plavix (Clopidogrel), Eliquis (Apixaban), Xarelto (Rivaroxaban), Effient (Prasugrel), Brilinta (Ticagrelor), Pradaxa (Dabigatron), Savaysa (Edoxaban), or Persantine (Dipyridamole)?
08
Do you take Aspirin?
09
Do you take Coumadin/Heparin/Warfarin?
10
Do you take Fish Oil, Omega 3, Vitamin D, Vitamin E, Turmeric, Glucosamine Chondroitin, or Multivitamin?
SITE QUESTIONS
11
Is the lesion found on the patient's forearm, wrist, or hand?
12
Is the lesion near the eyebrows or upper/lower eyelids or on the nose?
13
Is the lesion on the nose, lips, ear, eyelids or eyebrow, or has Dr. Chase indicated that patient will need a pain prescription?
MEDICAL HISTORY
14
Have you had Mohs before?
15
Have you been seen by Dr. Chase before?
16
Do you smoke or use nicotine or tobacco?
17
Do you have diabetes, hypertension, Hepatitis B / C, HIV, or kidney / liver dysfunction?
18
Problems with local anesthesia (Lidocaine / Novocaine / Marcaine) or with Epinephrine?
19
Are you applying any topical chemotherapy on or within 1 inch of the surgical site?
20
Do you use a wheelchair?
21
Are you able to recline flat or nearly flat?
22
Do you require oxygen supplementation?
23
Radiation history near surgical area?
ANXIETY
24
Do you experience intense anxiety when procedures are performed or feel you may need a one-time anxiolytic prescription?
MISCELLANEOUS
26
Additional notes: