NIS

Consultation

Medical clipboard

Please tell us about your medical concern and other medical problems which you have which may have a bearing on your treatment.

Click next to start.

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?

Finish