Call 216.591.1422

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About Dr. Grischkan
Get more information about Dr. Grischkan's background with hernia surgery.

Location
We're located in Beachwood near I-271 southeast of Cleveland, Ohio. View our map.

HERNIA CENTER OF OHIO MEDICAL QUESTIONNAIRE/REGISTRATION

For patients completing this questionnaire, be assured that all information is kept strictly confidential. If you are completing the Rapid Response on our web site Dr. Grischkarn, our medical director, will personally contact you after reviewing this information.

CONTACT INFORMATION

* DATE:

* NAME:

SEX:
M F
* DATE OF BIRTH:

* AGE:

* HEIGHT:

* WEIGHT:

* HOME ADDRESS:

Apt#:

* CITY:

* STATE:

* ZIP:

Country:

* OCCUPATION:

* EMPLOYER:

* BUSINESS ADDRESS:

Suite:

* CITY:

* STATE:

* ZIP:

Country:

CONTACT NUMBERS:

Home:

Cell:

Office:

* E-MAIL:

* EMERGENCY CONTACT:

* EMBERGENCY CONTACT TEL:

REFERRED BY (Select one):

Physician
Doctor's Name:

Address:

City:

State:

Zip:

Telephone:

INSURANCE (Select one):
Have Insurance Do Not Have Insurance
Cardholder's Name:

Insurance Company Name:

Group Number:

ID#

MEDICAL HISTORY

EACH line select YES or NO. If you mark YES-please check disorders in that section.
Yes No
Glaucoma Cataracts Stroke Seizures Mental Illness

Yes No
High Blood Pressure Heart Attack Chest Pain
Irregular Heart Rhythm Mitral Valve Prolapse Pacemaker Defibrillator Easy Bleeding Blood Clots Phlebitis

Yes No
Shortness of Breath Emphysema Pulmonary Embolus Asthma Disorder of Lung Chronic Cough

Yes No
Hiatal Hernia Acid Reflux Rectal Bleeding Ulcers Hepatitis Intestinal Cancer Chronic Constipation

Yes No
Kidney Stones Difficulty Urinating Frequent Nighttime Urinating

Yes No
Diabetes Thyroid Disorder Autoimmune Disorders

Yes No
Arthritis Orthopedic Metal Implants Deep Vein Thrombosis

Yes No
Cigarette Smoker Alcohol in Excess

Yes No
Other Medical Disorders Chronic Illness Cancer

FEMALES:
Pregnancy (how many) Live Births (how many)

ALLERGIES TO MEDICINES:
Yes None

*If Yes-which ones:

Current medications you are taking:
Name: Dose:
Name: Dose:
Name: Dose:
Name: Dose:
Name: Dose:
Name: Dose:

DO YOU TAKE BLOOD THINNERS: (Plavix, Coumadin, Aspirin, etc)
YesNo

HERNIA INFORMATION

LOCATION

SIZE

How long have you had the hernia:

Pain:
What is your pain level?

FAMILY MEMBERS WITH HERNIAS:
Yes None

*If Yes, please select which one(s)
Father Mother Brother Sister Child

PREVIOUS HERNIA SURGERY:
Yes No
Year Type of Surgery
Year Type of Surgery
Year Type of Surgery
Year Type of Surgery

PREVIOUS MAJOR SURGERY:
Yes None

*If Yes, please list below
Procedure 1:
Procedure 2:
Procedure 3:
Procedure 4:

If you need any assistance with this questionnaire,
please call our clinic at 216-591-1422.