Patient’s Name: ___________________________________________________

Date of Birth / /
Today’s Date / /________

Have you been diagnosed and/or treated for any of these conditions?

(Please Check All That Apply)
_______Irregular Heart Beat (arrhythmia) _______Kidney Disease requiring Dialysis ______Inflammatory Bowel Disease (Crohn’s Disease or Ulcerative Colitis) Cancer, please specify:________________________________ Skin Cancer BCC___________________________________SCC_____________________________________________ Melanoma site____________________when diagnosed_____________________ treatment______________________ Have you received a Blood Transfusion? Y or N Have you received X-ray Treatments for Acne? Y or N Have you received Light Treatment for any Kind of Skin Condition? Y or N Have you received Radiation Treatment for a Cancer? Y or N
Do You?
(Please check All that apply)
Require Antibiotics Prior to Dental Procedures? Develop Rashes / Reactions to Bandages / Tapes / Antibiotic Ointments?
Do you have any other medical conditions not previously mentioned? If yes, please list:
Please list all major SURGERIES:_______________________________________________________

Females Only: (
if the patient has not undergone changes of puberty, circle n/a) N/A
Do you develop frequent yeast infections when taking antibiotics? Y or N Have you had your uterus removed (hysterectomy)? Y or N Have you had your ovaries removed? Y or N Have you had one or more miscarriages? Y or N Y or N If so, when was last menstrual period? ___________
Medication History:

Do you have any Medication Al ergies? Y or N If yes, please list: __________________________________________________________ Other Al ergies? Seasonal/foods/environmental? _________________________________ _______________________________________
Please list all medications you are currently taking (prescriptions, over-the-counter meds, vitamins & herbal supplements):
______________________ ____________________ Patient’s Name: ______________________________________________
P. 2 Med Hx
Do you ever take aspirin, ibuprofen (Motrin, Advil) naproxen sodium (Al eve, Naprosyn), vitamin E supplements, garlic, ginger, gingko or ginseng supplements? If yes, please list the items you do take and describe how often. ____________________________________________________________________________________________________ Have you ever had a reaction to local or general anesthesia? Y / N Have you ever had a reaction to Epinephrine?
Family History:
Do you have any family members (father, mother siblings or child) with the fol owing conditions?
(Please check ALL that apply.)
____ Skin Condition (Please List)________________________ Are there any other diseases / conditions which run in your family? If yes, please list:_______________________________ Social History:
Married / Separated / Divorced / Partnered Do you use tobacco products of any kind? Y or N If yes, list type_____________________ Amount per day___________________ If yes, how much? (# of drinks per day, week, or month)________________________ Do you or have you ever used recreational drugs? Y or N If yes, what? _______________________ Route taken? (Oral, IV, nasal, smoke) Have you ever been exposed to HIV? Y or N What is your occupation?_______________________________________________________ Hobbies?_______________________________________________________________ Review of Systems: Are you experiencing any of the fol owing symptoms currently or in the last 6 months?
(Please check ALL that apply)
Women Only:
Digitally signed by Skin Solutions Dermatology DN: cn=Skin Solutions Dermatology, o=Skin Solutions, c=US When exposed to the sun in the spring (first significant sun exposure of the warm season), do you (Please check ONE)
_____ Sometimes Burns, Always Tans (I I) Patient Signature __________________________________ Date / / Reviewed & Updated / / Initial . Legal Representative__________________________________ Date / / Reviewed & Updated / / Initial . Physician’s Signature Date / / Update Reviewed / / Initial . 7 West 24th Street, 1st Floor, New York, NY 10010  T 646.559.0843 F 646.559.0845


Cimzia® (certolizumab pegol)

Cimzia® (certolizumab pegol) COVERAGE CRITERIA DRUG CLASS: GI Drugs, Miscellaneous – AHFS 56:92 BRAND NAME: Cimzia® GENERIC NAME: certolizumab pegol POLICY #: 0261 CATEGORY: Commercial FDA INDICATIONS : • Crohn’s Disease (CD) – for reducing signs and symptoms of Crohn’s disease and maintaining clinical response in adult patients with moderately to severely a

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