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. Grischkan, our medical director, will personally contact you after reviewing this information.



CONTACT INFORMATION























































































 

MEDICAL HISTORY


EACH line select YES or NO. If you mark YES-please check disorders in that section.

































 Other medical disorders/chronic illness/cancer

 



 


 


*If Yes-which ones:

 








 


 


HERNIA INFORMATION








 




 


 


*If Yes, please select which one(s)

 







 


 


*If Yes, please list below




 

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