FU-Q · about 8 minutes
Please answer what you can — every answer helps Dr. Kim prepare for your visit. Skip anything you are unsure about.
Your answers are encrypted in this browser before they are sent. Only SSMC clinic staff, using the clinic’s private key, can read them. Staff add them to your medical record and then delete them from this website; anything not deleted is erased automatically after 30 days. Nothing is saved on this device after you close the page.
Fields marked * are required. Everything else: answer what you can; if you are not sure, leave it blank and ask the doctor.
Check anything you have noticed recently (in the past few weeks). This helps your doctor decide whether any symptom needs attention before a procedure. If you check any item shown in bold, please tell the front desk or nurse right away — these may need to be looked at before your procedure.
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Secure patient forms
Encrypted on your device
Secure patient forms
Encrypted on your device