Patient Questionnaire
1. Name:
____________________________________
2. Next of Kin:
_____________________________________
3. Alternate Next of Kin:
_________________________________
4. Do you have a lawyer? Yes □ No
□
5. Are you a lawyer? Yes □ No □
6. If YES to either 4 or 5, are you or do
you have a GOOD lawyer? Yes □ No □
7. Have you ever seen Dr. Zoidberg before?
Yes □ No □
8. If YES to 7, explain your survival:
________________________________________
9. Are you a reporter or undercover
journalist? Yes □ No □
10. Please select the outcome(s) for your
visit today that are least objectionable to you:
□ Death
□ Coma
□ Decapitation
□ Paralysis
□ Death
□ Blindness
□ Amputation □
Sterility □ Death
11. If you DID NOT select death in
10, would it be acceptable anyway? Yes □ No □
12. What is your main reason for seeing the
doctor today? _________________________
13. Do you realize that the condition you
described in 12 could result in your death in the very near future, like while
Dr. Zoidberg is treating you? Yes □ No □
Finally, by signing below, you certify that
you understand the risks of partaking in medical treatment by Dr. Zoidberg.
These risks include, but are not limited to; death, dismemberment, pain,
suffering, loss of any number of motor functions, loss of memory, gain of
memory, loss of bladder control, loss of organs, crippling psychological damage,
plain old crippling, and ringing in the ears. You also certify that any and all
improvement in your condition is purely coincidental. Dr. Zoidberg takes no
responsibility for articles left unattended while you are anesthetized; this
includes, but is not limited to, wallets, credit cards, car keys, breath mints,
gum, lint or actual food. All payment is due BEFORE seeing the doctor.
Signature
____________________________________ Date ____________________