When you return to the previous screen and begin your medical information questionnaire,
there will be four ways to select the appropriate questionnaire.

1. Select your questionnaire from a list similar to the one below.

  Adult Physical Exam                    Pre-Operative Checkup
  Pediatric Well Visit Checkup       Adolescent Checkup
  Sports Physical                           Backache
  Diabetes                                     Cough
  Sniffles / Sinuses / Flu                Urinary Track Infection
  Kidney Stones                            Abdominal Pain
  Joint Pain                                    Hypertension
  High Cholesterol                         Headache Fatigue

2. Select your questionnaire by typing a term that best describes your condition.  
Below are some common concerns you can use.

 Medicare Annual Wellness Visit - type in "annual wellness visit"

 Headache - type in "

 Cough with or without fever, sputum or trouble breathing - type in "

 Any kind of joint swelling, pain, or difficulty moving joints - type in "
joint pain"       

 Back pain in any part of the back - type in "
back pain"        

 Discomfort or burning when you urinate, any trouble urinating, possible urine
 infection - type in "
difficulty urinating"       

 Any problems with your bowel movements - type in "

 Ear pain, with or without fever, discharge - type in "

 Routine examination - type in "
physical exam"      

 Trouble sleeping - type in "

 Nervous, anxious, unable to focus or concentrate - type in "

 Depressed, down, unable to get going - type in "

 Dizzy, lightheaded, trouble with balance - type  in "

 Hypertension, high blood pressure - type in "
high blood pressure"       

 Diabetes or concern about possible diabetes - type in "

 Sick child - type in "
sick child"   (Be sure to enter correct birth date for child.)

 Well child visits (up to age 10) - type in the child's age followed by "
well child"
 (For example, "
4 month well child" for a 4 month old follow up visit.)

 Abdominal gas, bloating, burping, belching - type in "

 Difficulty swallowing food or drinks - type in "
difficulty swallowing"       

 Cold, sore throat, sinus problem - type in "

 Menstrual period abnormality - type in "

3. Select a questionnaire using the recommendation made when you scheduled your

4. Ask our staff to help you select a more specific questionnaire from the
list.  Just let us know if you need this help.

Tips For Getting The Most From Your Upcoming Appointment

1. If no other conditions listed above fits your need or if you are unsure then type in one of the
following conditions:    
  a. "
general exam"   
  b. "
health risk profile"

Both of these phrases will guide you in finding the right questions and can be used any time
you are unsure of what condition to use.  While you will be ask more questions, you will also
have more opportunities to share information with Dr. Neighbors.

2. If you start out with the wrong questionnaire, you can still start over with a new concern.  

3. You can list as many concerns as you like separated by commas.

4. If you think that two concerns are related to each other, use only the main one.  For example,
if you have a cough and a fever, but you think that the fever might be caused by the cough,
enter "cough" as your concern. The questionnaire will automatically ask you about your fever.  

5. If our staff, suggested a concern, then use that as a starting point and include other
concerns as needed.  You may also use the
expanded list of patient concerns to choose from if

6. Be sure that your gender and age are correct.  Your individualized questionnaire will be
based on your age, gender and condition.  

7. Remember that the reason you are answering this questionnaire is to provide Dr. Neighbors
with information that is important for your care.  Be sure to be as specific as you can about your

8. If a question doesn't provide an answer choice that adequately meets your need then make
a note to discuss this during your appointment.
How To Select Your Medical Information Questionnaire