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Dermatology Medical History Questionnaire Mobile App

The Dermatology Medical History Questionnaire mobile app provides dermatologists with a detailed medical history. The app documents the following: patient information, pharmacy, medications, personal health history, skin cancers, women, medicare and full body examination. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

Want to learn more about GoCanvas?

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Take a peek inside the Dermatology Medical History Questionnaire Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico statictext

    All questions contained in this questionnaire are strictly confidential and will become part of y...

  • Ico date

    Today’s Date:

  • Ico textbox

    Name

  • Ico checkbox

    Male

  • Ico checkbox

    Female

  • Ico date

    Date of Birth:

  • Ico multiline

    Address

  • Ico textbox

    Primary Phone Number

  • Ico textbox

    Email

  • Ico textbox

    Social Security Number

  • Ico statictext

    This number will be used to uniquely identify you for any lab results, pharmacy verification or h...

  • Ico textbox

    What is your Occupation?

  • Ico textbox

    Employer Name:

  • Ico multiline

    What is your primary complaint(s) today?

  • Ico textbox

    How did you hear about our office (Referral from my Doctor, Yellow pages, Internet, from my insur...

  • Ico statictext

    Ethnicity:

  • Ico checkbox

    Asian

  • Ico checkbox

    Black/African American

  • Ico checkbox

    Hispanic

  • Ico checkbox

    Caucasian

  • Ico checkbox

    Other

  • Ico textbox

    Previous or referring doctor

  • Ico date

    Date of last physical exam

  • Ico textbox

    Pharmacy You Regularly USE (Name & Location):

  • Ico textbox

    Name of the Drug

  • Ico multiline

    Reaction You Had

  • Ico textbox

    Name of the Drug

  • Ico textbox

    Strength

  • ...and More!

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