Adult Intake Form for Dr. Wiancek - part 1

A Note to the Patient: Please complete the questionnaire as thoroughly as possible in order for the physician to have a complete picture of the patient physically, mentally, and emotionally. This is a confidential record of your medical health history and will not be released except where you have authorized me to do so. Thank you.

Caution: Data on this form are not stored. To avoid loss of data, do not leave the form without submitting at the end of page.