When you visit Dr. Cotlers office there is a lot of information to share between the two of you in a short amount of time. It's easy to forget important questions or details that your doctor needs to know. This questionnaire is designed to help you get the most from your visit so you can feel your best.

Take a few minutes to fill out this form, print it, and take it with you to Dr. Cotlers office.

Tip: There are only 5 lines available per question, so summarize information as much as possible. If you type more than 5 lines it won't show on the printout.

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.

Reason for your visit:

When did the problem start?

What makes the problem worse?

How have you tried to treat your condition?

List any medicines you've taken for the problem.

(Your Additional Question Goes Here.)

(Your Additional Question Goes Here.)

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IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.