GCD - Health History

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
Pharmacy Name:*
Pharmacy City
Pharmacy Phone:*
Please enter a valid phone number.
Describe your current problem:*
Height*
Weight*
How long have you had this problem?*
Have you ever had it before?*
Does it?*

ItchOozeBurnBleedOther
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*
No medications
Allergies to Medications:*
None
List all your medical problems and past surgeries: *
Did you get a flu shot?Did you get a pneumonia shot?
REVIEW OF SYSTEMS [Please check if you have a history of]:
Allergic to Latex/Rubber/Nickel/FoodArthritisAre you breast feeding?Blood/Bleeding DisordersCancer (Non-Skin)DiabetesHave a pacemaker or defibrillator?Take antibiotics prior to surgical procedures?Have an artificial joint or heart valve?Heart DiseaseHigh Blood PressureImmunologic DiseaseInfectious DiseaseKidney DiseaseLiver DiseaseForm KeloidsAre you pregnant?Do you plan on becoming pregnant soon?Lung DiseaseMelanomaSkin CancerSkin DiseaseThyroid DiseaseOther
Please check if there is a FAMILY history of:

AcneActinic KeratosisAlopeciaArthritisAsthmaBasal Cell CarcinomaBreast CancerColon CancerCancerContact DermatitisDiabetesEczemaHair LossHay FeverHivesLupusMelanomaNail DiseaseNeoplasmPrecancerous LesionsPsoriasisSkin CancerSquamous Cell Carcinoma
Marital Status

SingleMarriedDivorcedWidowedOther
Do you live alone?Do you drink alcohol?Do you smoke?
Occupation:
Hobbies/Leisure:
Reviewed By: _______________________
Date*

MonthDayYear
Date
Should be Empty:

GARDEN CITY DERMATOLOGY

HEALTH HISTORY

REVIEW OF SYSTEMS [Please check if you have a history of]: