At Block Center, we believe the best care begins with a doctor patient relationship built upon open and honest communication. This process begins with the attached 10-part patient questionnaire. By obtaining a detailed case history from you, we are able to tailor a program that addresses your biological, physical, biochemical, and emotional needs. You probably have never had to fill out forms as long and detailed as these -- and certainly not in a doctor's office.  Let us explain the nature of our questionnaire, why we ask you to take the time and trouble to fill it out carefully, and show you how it will be used to your benefit.

Whatever the word "scientific" means, it certainly does not apply to a good part of what a doctor does and should do.  For example, two patients could come to our center -- same age, weight, height, lab reports, complaints, and even (in general) the same past history.  And yet, we, and most concerned physicians, should be able to detect significant differences between them which would not appear as part of a purely "scientific" examination.  Those differences have to do with the individual nature of the patient -- which can often be determined only after an extensive relationship. 

These "non-scientific" components of a patient's personality, such as background, lifestyle, stresses, worries, and past and future concerns are as much a part of what a physician must be aware of as biological information such as blood pressure and blood cell count.  For example, if we sense that a patient is somewhat frightened, the blood pressure reading means something quite different than it appears on the surface.   Even the most seemingly innocent piece of information may provide us with an insight we might not have otherwise identified to aid direction in providing the best possible care.

In case of difficulty: Should you find any part of the questionnaire difficult, or if you would feel more comfortable if one of our Patient Advocates were to assist you in filling it out, please do not hesitate to call.

If you prefer not to fill this questionnaire out:  Although we believe we can provide you with far better care if we are armed with the most complete history, we are always sympathetic to your needs.  We do not want  you to feel pressured to fill out this form.  All you need do is inform members of our staff that you prefer not to fill the questionnaire out, and we will proceed without it. 

Confidentiality:  In all relationships with our staff, absolute confidentiality is assured, including the questionnaire material.  The confidentiality of the doctor-patient relationship applies to our entire staff and to all materials in your case history file.

Kindly mail the completed questionnaire to our office rather than faxing it.

Download our Short-Form Patient Questionnaire in Word format (right click and choose save target as).

Patients wishing to provide a more comprehensive picture of their health history may download our comprehensive Patient Questionnaire in Word format (right click and choose save target as).