help us understand your case
Enable to better understand your condition and consider the best treatment, we'll need you to fill in this medical questionnaire.
All information will be kept confidential and will be exclusively used for the evaluation of your health, please try to make it as accurate and complete as possible. You might consult your doctor and request his/her help filing it. Please take your time and complete it carefully and thoroughly, and then review it to be certain you have not left anything out.
If you have questions or concerns, we will help you with those after this form is completed. We realize that some parts of the form will be unclear to you. Do your best to complete the form. Your questions will be thoroughly addressed afterwards. It might be helpful for you to keep a written list of questions or concerns as you complete the medical history form.
If you prefer to fill paper form, Click Here to download the Medical History Questionnaire, fill it and e-mail us a scan copy.