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#1 Rated Hernia Doctor
216-591-1422
Medical Form
Hernia Center of Ohio
#1 Rated Hernia Doctor
Home
Meet Dr. David Grischkan
History – Hernia Center of Ohio
Hernia Conditions
Inguinal Hernias
Shouldice Hernia Repair Technique
Hernia Surgery Repair Technique – Surgical Tour (Panel 1)
Hernia Repair Surgery Technique – Surgical Tour (Panel 2)
Hernia Repair Surgery Technique – Surgical Tour (Panel 3)
The Shouldice NON-MESH Tissue Repair – Surgical Tour (Panel 4)
The Modified Shouldice Hernia Surgery Technique – WITH MESH (Panel 5)
Femoral Hernias
Incisional Hernias
Ventral / Umbilical Hernias
Sports Hernias
What Patients Say
Bodybuilding Champions
Doctors
Insurance/Self Pay
Contact us
Home
Meet Dr. David Grischkan
History – Hernia Center of Ohio
Hernia Conditions
Inguinal Hernias
Shouldice Hernia Repair Technique
Hernia Surgery Repair Technique – Surgical Tour (Panel 1)
Hernia Repair Surgery Technique – Surgical Tour (Panel 2)
Hernia Repair Surgery Technique – Surgical Tour (Panel 3)
The Shouldice NON-MESH Tissue Repair – Surgical Tour (Panel 4)
The Modified Shouldice Hernia Surgery Technique – WITH MESH (Panel 5)
Femoral Hernias
Incisional Hernias
Ventral / Umbilical Hernias
Sports Hernias
What Patients Say
Bodybuilding Champions
Doctors
Insurance/Self Pay
Contact us
Rapid Response Medical Form – Hernia Center of Ohio
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Date:
 10/15/2024
All information is kept strictly confidential. Please click SUBMIT when finished. For online questionnaires, Dr. Grischkan will call you after reviewing your medical information. The phone call will identify an UNLISTED number. If you have any questions please call our clinic at 216-591-1422.
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Benin
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Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
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Denmark
Djibouti
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Dominican Republic
Ecuador
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Ethiopia
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Gabon
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Ghana
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Greenland
Grenada
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Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
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Iran
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Isle of Man
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Italy
Jamaica
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New Caledonia
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Niger
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Niue
Norfolk Island
North Macedonia
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Norway
Oman
Pakistan
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Palestine, State of
Panama
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Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
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Saudi Arabia
Senegal
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US Minor Outlying Islands
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Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Office Phone:
Referred by:
Physician
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Physician's Name:
Physician's Address:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Physician's Phone:
Non-Physician Referrer's Name:
Non-Physician Referrer Type:
Patient
Family Friend
Newspaper
Internet
Other
Insurance:
No
Yes
Organization Sharing
Cardholder's Full Name:
Insurance Company Name:
Insurance Company Phone:
Group Number:
ID Number:
Worker's Compensation Claim?
No
Yes
Date of Injury:
How did you get injured?
Medical History
For each section, please select any of the following disorders that you suffer from. Select none, if the section does not apply to you.
Head and Neck Disorders
none
glaucoma
stroke
seizures
anxiety
depression
mental illness
Alzheimer's / dementia
Other
Head and Neck Disorders-Other, please explain
Heart Conditions
none
irregular heart beat
heart attack
chest pain recently
high blood pressure
congestive heart failure
pacemaker
mitral valve prolapse
blood clots
other
Heart Attack Year
Heart Conditions-Other, please explain
Lung Disorders
none
asthma
COPD (emphysema)
chronic cough
pulmonary embolus
shortness of breath
other
Lung Disorders-Other, please specify
Gastrointestinal Disorders
none
acid reflux (GERD)
Crohn's disease
ulcerative colitis
hepatitis
cirrhosis
rectal bleeding (black stool)
chronic constipation
hiatal hernia
ulcers
other
Gastrointestinal Disorders-Other, please specify
Urinary Disorders
none
frequent urinary tract infections
kidney stones
kidney failure
frequent nighttime urination
bloody urine
difficulty urinating
other
Urinary Disorders-Other, please specify
Endocrine Disorders
none
diabetes
thyroid condition
adrenal disorder
autoimmune disorder
Diabetes Type
Thyroid Condition Type
Autoimmune Disorder Type
Hematologic Disorders
none
anemia
leukemia
clotting disorder
hemophilia
abnormal bleeding
lymphoma
other
Hematologic Disorders-Other, please specify
Taking Blood Thinners
No
Yes
Blood Thinner Name
Blood Thinner Dose
Medical History (continued)
For each section, please select any of the following disorders that you suffer from. Select no, if the section does not apply to you.
Orthopedic Conditions
No
Yes
If yes, which orthopedic conditions?
arthritis
metal implants
other
Orthopedic Conditions-Other, please specify
Gynecologic
No
Yes
Number of Pregnancies
Neurologic Conditions
No
Yes
Type(s) of Neurologic Condition(s)
Cigarette Smoker
No
Yes
How often do you smoke (i.e. packs a day)?
How many years have you smoked?
Alcohol in Excess
No
Yes
How many alcoholic drinks do you have per week?
Recreational Drugs
No
Yes
Types of Recreational Drugs that you take
History of Cancer
No
Yes
Type(s) of Cancer
Steroid Use (12 months)
No
Yes
Names of steroids that you take
Sleep Apnea
No
Yes
Illness in the Past 30 Days?
No
Yes
If yes, please describe the illness
Chronic
No
Yes
If yes, please describe the chronic condition
Any Medical Problems/Serious Illness?
No
Yes
If yes, please describe the medical problem
Do you or a close relative have a problem with anesthesia or muscle disease?
No
Yes
If yes, please describe the close relatives disease
Allergies to Medications
No
Yes
If yes, which medicines are you allergic to?
Latex Allergy
No
Yes
Current Medications
None
Yes
Medications:
Select + symbol to add medications.
Name
Dose
Hernia Information & History
Please describe the hernia(s) you are experiencing. Select none, if the section does not apply to you.
Hernia Information
Duration - How many months or years has hernia been present?
Size - marble | golfball | orange | huge
Pain - 0=none, 10=excrutiating
Pain Type - Burning | Stabbing | Cramping | Pressure (use more than one if needed)
Location
Duration
Size
Pain
Pain Type
Limitations Caused by Hernia Pain
No
Yes
If Yes, which limitations? Examples: Exercise, sex, lifting, standing, etc.
Family History of Hernias
None
Yes
Family Members Affected
Father
Mother
Brother
Sister
Child
Previous Hernia Surgery
None
Yes
List Hernia Type (inguinal, umbilical, etc.), Location (right, left, etc.) and Month/Year:
Select + symbol to add surgeries.
Hernia Type
Location
Month/Year
Previous Non-Hernia Surgery
None
Yes
List Type and Month/Year:
Select + symbol to add surgeries.
Type
Month/Year
Δ
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