Yearly Patient Questionnaire Form (This is NOT the yearly required DOH registration form)

I understand that the information I have been asked to provide is for the diagnosis and treatment of the medical condition for which I am seeing the physician today, and that if I have not accurately and completely disclosed the requested information, it may adversely impact the physician's ability to diagnose my condition and recommend appropriate treatment.I certify that the information in this questionnaire is truthful, accurate and complete.