Buursma Agency

Pre-Screening Questionnaire

  • Please give complete details of all YES answers to questions, including but not limited to all dates, diagnoses, duration, outcome, treatments and medications prescribed.
  • Have you ever had, been told by a member of the medical profession that you have, or been diagnosed with or treated for:

Family History


  • Mother

  • Brothers

  • Sisters



Scroll to Top
Skip to toolbar