GCD - Health History - June 2023

GARDEN CITY DERMATOLOGY
HEALTH HISTORY
Patient Name

First NameLast Name
Age
Did a healthcare provider refer you here? (M.D. ,P.A., N.P., etc)
Name
Tel
Format: (000) 000-0000.
Pharmacy Name:
Pharmacy City
Pharmacy Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Describe your current problem:
Height
Weight
How long have you had this problem?
Have you ever had it before?
Does it?

Other
What are you using for it?
Have you recently stopped using any medications?
What treatment have you received in the past for this problem?
Have you seen another dermatologist?
Dr.’s Name:
List of medications
Allergies to Medications:
List all your medical problems and past surgeries:
REVIEW OF SYSTEMS [Please check if you have a history of]:
Other
Please check if there is a FAMILY history of:
Marital Status

Other
Occupation:
Hobbies/Leisure:
Reviewed By: _______________________
Date

MonthDayYear
Date
Should be Empty: