If you believe this is an emergency, call 911 IMMEDIATELY or go IMMEDIATELY to the Emergency Room. Symptoms such as chest pain, chest pressure, shortness of breath, or blood loss may require immediate medical attention.

When you have a medical problem, it's important that we have all of the information needed to reach the very best decisions about your diagnosis and treatment.

Through this questionnaire, you will be asked a series of questions that capture your medical history and describe the symptoms of your present illness. Please complete this questionnaire shortly before your visit, so that the information will be as current as possible.

When you have finished, you will see a summary of your symptoms. At that time, your information will be securely transferred to our medical office. There may be additional items that are not asked that you may wish to mention to your physician. Answer as accurately as you are able. Your answers will be reviewed by your health care provider prior to your visit.

Your health information is confidential and will only be shared with your provider.