NIS

New Patient General Medical Survey Online.

This survey is routine for every doctor I know who are accepting new patients. The only difference is that they make you fill out extensive paper forms. Ours is online fun and easy.

Click next.

What can we help you with?

Hernia

What are your symptoms?

You are:

Male Female

Where? (click the figure, click again if you need to correct)

Male Female

How long have you had this?

  • Days
  • Weeks
  • Months
  • Years
  • Decades

How severe are your symptoms? 10 is worst.

Decrease
  • 0
  •  
  • 2
  •  
  • 4
  •  
  • 6
  •  
  • 8
  •  
  • 10
Increase

What radiology imaging studies have you had?

Review of systems. Do you have?

What exercise do you do?

Do you?

What surgery have you had?

What medical problems do you have?

What medications do you take?

Do you have any medical allergies?

Do you have any questions or additional information for us?

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