We have learned that it is hard to remember everything you want to tell us when you are sitting in our offce. We want to know as much as we can about your concerns and living circumstances, and have found that asking many of our questions ahead of your visit makes it easier for everyone involved. Please answer the following questions to the best of your ability. Some of the items will probably not apply to your situation, however we live in diverse world and hope to not overlook possibilities. The more you tell us, the better the job we can do to address your concerns. If a section of the questionnaire doesn’t apply to you (for example occupational history for a child), or if you prefer to not answer any questions that's ok - just skip to the next one!
Please provide us with appropriate email addresses- we will never share them with others without your permission
Please provide us with additional contact information of important persons in the primary patient's life - we will never share them with others without your permission
The following questions help us to understand the patient's growth and development, which is sometimes useful in understanding their current situation. Many of the items may not apply, or may be hard to remember, but please give us as much information as you can!