Please click on this link to download the questionnaire to fill out and bring to your visit to see a physician in the department.  You will need Adobe Acrobat a free download.

Steps

1.  Click on the link to download the questionnaire (95 KB).  This is a pdf (portable document format) file that requires Adobe Acrobat Reader to open it.  If you already have this software, the questionnaire will automatically be opened.   If you do not have this software you can get it by clicking on the logo below.  Adobe Acrobat Reader is a large file (over 8 MB) and can take as much as an hour to download if you have a slow connection to the Internet.
  (click to get Adobe Acrobat Reader)

2.  Print the questionnaire (4 pages), fill out and sign it.

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  © Cleveland Clinic 2002 | Maintained by Neil Mehta, MD, Anil Jain, MD
last updated on 11/06/01