360 S. Garden Way, Suite 250
Eugene, Oregon 97401
PHONE: 541-255-3205
FAX: 888-864-3381

Medical & Lifestyle History

Please complete the following questionnaire prior to your consultation with Dr. Perry. All responses are confidential and viewed solely by the physician.

If you prefer, you may download and print the Medical and Lifestyle History by clicking here. Please complete the form and either fax to Dr. Perry at 888-864-3381, or bring with you to the initial consultation.

Confidential Medical History Questionnaire