Complete the survey here and hit "Submit" at the end to email to a physician.
If you do not have the time to complete on-line, Click here to PRINT SURVEY, fill it out in your free time and either email it to us at firstname.lastname@example.org or FAX at 305-932-2223. Once reviewed, you will be contacted via email or phone with further information for a course of treatment.
You should fill in the box with number 3 if:
This is a condition that you are feeling most of the time or it is one of the main reasons you are seeking medical help. You would also mark as "3" if you come across a condition such as "Osteoarthritis" or "Low Blood Pressure" or "Menopause"; and you have been diagnosed with that condition or had it in the past . In other words, the number three is the strongest possible answer you can give.
You should fill in the box with the number 2 if:
This is for symptoms that occur several times a year. You could call this a "moderate" type of problem.
You should fill in the box with a number 1 if:
This is for symptoms that occur several times a year but the symptoms are "mild". This is the kind of symptom that you notice but that nothing comes out.
If the question doesn't apply to you at all (other then as a part of gender specific group)
please put "0" in the box so we know you didn't just miss it by accident.