Clearview Dermatology Health Evaluation Form

Health Evaluation Form
PLEASE ALLOW 3-5 BUSINESS DAYS FOR PROCESSING THIS ONLINE FORM TO YOUR CHART.*

I UNDERSTAND THAT IF MY APPOINTMENT IS WITHIN THE NEXT 1-2 BUSINESS DAYS THIS HEALTH EVALUATION FORM MAY NOT BE PROCESSED AT THE TIME OF CHECK-IN, AND I MAY BE ASKED TO COMPLETE AGAIN.
The following questionaire is a comprehensive look at your health. It will take about 5 minutes to complete.
Full Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender*

MaleFemale
Phone Number*

Area CodePhone Number

Do wear Sunscreeen?*

YesNo
Do you have a family history of Melanoma?*

YesNo
Cigarette Smoking Status:*

Currently SmokesHave smoked in the pastNever SmokedOther
Medications: (Please list all current medications).
Allergies: (Please list all allergies).
Preferred Pharmacy (Name & Number)*