New Patient Intake - Comprehensive
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- Carmella Hudson
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1 Sajad Zalzala, MD Board Certified Family Medicine 1400 Provincial Road Windsor, ON N8W 5W Fax: New Patient Intake - Comprehensive Welcome to the office of Sajad Zalzala, MD located inside of Coral Medical Centre! This is your new patient intake form. Please take the time to read, fill out, and sign the appropriate sections. Please plan to arrive 15 minutes prior to your scheduled appointment time as this allows us to better take care of your needs. If you wish to cancel or reschedule your appointment please contact our office 24 hours or more in advance. It is our goal to provide each of our patients the best care possible. If you feel you have been treated otherwise please let us know. Please help us better take care of your needs by filling out the attached comprehensive health questionnaire. Last Name: First Name: MI: Date of Birth: Age: Height: Weight Address: #: City: Province: Postal Code: Home Phone: Cell Phone: Emergency Contact: Name Telephone: Occupation: How did you find out about us? How would you rate your health in general? Excellent I feel the best I have ever felt Good I feel there is room for improvement Okay - I don t have any major illnesses, but I just don t feel great Below average I have a few health problems Poor I have or am developing many health problems Which of the following describes your approach to health: Very proactive always looking for ways to improve my health Somewhat proactive I will improve my health only if it s convenient Neutral I live my life and hope my health will be fine Reactive I only seek to treat health problems that bother me Negative my health is poor or will eventually be poor, so what s the point
2 Past Medical History Have you been diagnosed with any of the following illnesses? Illness Yes No Year How was it diagnosed? Anemia Asthma Blood clots High blood pressure High cholesterol Cancer Chronic fatigue syndrome Gestational Diabetes Diabetes Endometriosis Fibromyalgia Glaucoma Hepatitis Heart disease HIV/AIDS Kidney stones Migraine Thyroid disease Seizures Sleep apnea STD's Stroke Others: Accidents or Major Trauma (Please list dates. For scars please give locations):
![Surgeries/Hospitalizations (Please list dates): [ ] Colostomy [ ] Esophageal [ ] Cholecystectomy [ ] Gastric [ ] Ileostomy [ ] Nephrectomy [ ] Hemorrhoidectomy [ ] Tonsillectomy [ ] Appendectomy [ ]](/docs-images/89/97520389/images/3-0.jpg "Bowel (intestinal) [ ] Vasectomy [ ] Hysterectomy (partial or complete) [ ] Other Dental Procedures (Root canals, total number of cavities, etc): Allergies and/or Sensitivities (Drugs, chemicals,")
![foods, environmental): Occupational Exposures (i.e. mercury, asbestos, etc): Lifestyle Habits Do you currently smoke or use tobacco? [ ] Yes [ ] No If yes, how much and for how long?](/docs-images/89/97520389/images/3-1.jpg "cig/day for years If you have smoked in the past, what year did you quit? mo / yr Do you routinely wear a seat belt? [ ] Yes [ ] No Do you have any pets? [ ] Yes [ ] No How often do you exercise?")
3 Surgeries/Hospitalizations (Please list dates): [ ] Colostomy [ ] Esophageal [ ] Cholecystectomy [ ] Gastric [ ] Ileostomy [ ] Nephrectomy [ ] Hemorrhoidectomy [ ] Tonsillectomy [ ] Appendectomy [ ] Bowel (intestinal) [ ] Vasectomy [ ] Hysterectomy (partial or complete) [ ] Other Dental Procedures (Root canals, total number of cavities, etc): Allergies and/or Sensitivities (Drugs, chemicals, foods, environmental): Occupational Exposures (i.e. mercury, asbestos, etc): Lifestyle Habits Do you currently smoke or use tobacco? [ ] Yes [ ] No If yes, how much and for how long? cig/day for years If you have smoked in the past, what year did you quit? mo / yr Do you routinely wear a seat belt? [ ] Yes [ ] No Do you have any pets? [ ] Yes [ ] No How often do you exercise? [ ] none [ ] 1-2 x/wk [ ] 3-4x/wk [ ] daily How much soft drink do you consume? [ ] none [ ] 1-2 x/wk [ ] 3-4x/wk [ ] per day How much alcohol do you consume? [ ] none [ ] 1-2 x/wk [ ] 3-4x/wk [ ] per day How much fast food do you consume? [ ] none [ ] 1-2 x/wk [ ] 3-4x/wk [ ] per day How much coffee do you consume? [ ] none [ ] 1-2 x/wk [ ] 3-4x/wk [ ] per day Are you sexually active? [ ] Yes [ ] No Marital Status: [ ] Single [ ] Co-habitating [ ] Married [ ] Divorced [ ] Widowed How many sexual partners have you had in the past year? Are you using a form of contraception? [ ] Yes [ ] No [ ] N/A Have you ever had a sexually transmitted disease? [ ] Yes [ ] No Have you ever had a blood transfusion? [ ] Yes [ ] No Have you ever used intravenous drugs? [ ] Yes [ ] No Please circle the type of bowel movements you typically have: Frequency x per week
4 Nutrition restrictions: [ ] Lactose Intolerance [ ] Vegetarian Diet [ ] Vegan Diet [ ] Religious (Kosher, Halal, etc.) [ ] Salt restricted [ ] Gluten-free Diet [ ] Other [ food intolerances/allergies [ ] Other diet : Please list and describe below. Nutritional Supplements Please use the chart below to list all vitamins, minerals, amino acids, or other supplemental products (meal replacement drinks bars, etc.) you are currently taking. Supplements Brand Form Dose/Frequency Length of Time For Example: Vitamin E Nature s Made Soft gel cap 400 IU/1 X Day 6 Months Medications Please list all medications (prescription and over the counter) you are currently taking Medication Physician Contact# Length of time Dose Frequency For Example: Ibuprofen OTC 1 week 400 mg 2 X day What are your goals and expectations by seeking treatment here? Short term? Long Term? (try to be specific)
5 24-Hour Diet Recall: Please list all the foods and beverages you have consumed in the past 24 hours. BREAKFAST: LUNCH: DINNER: SNACKS: Have you had: No Yes If yes, when? Month/Year Blood pressure check / Result? Urinalysis / Diabetes Screening / Glaucoma Screening / Eye exam / Chest X-ray / Cholesterol test / Stress Test (for heart) / Test of stool for blood / (Stool Guaiac Test) Colonoscopy / Flexible sigmoidoscopy / Rectal exam to examine prostate (males) / PSA blood test for prostate (males) / Mammogram (females) / Pap/pelvic exam (females) / Bone Density Test (females) /
6 Family History Father: Mother: Paternal grandfather Paternal grandmother Maternal grandfather Maternal grandmother Siblings: If Living, Age? If deceased, cause and age of death? Have any of your relatives had the following? Heart disease (Heart attack, heart surgery, etc) Stroke High Blood Pressure High cholesterol Diabetes Thyroid Disease Breast Cancer Other Cancer(s) Depression Mental Health disorder Suicide Osteoporosis Alcoholism Drug Abuse Migraines No Yes If yes, which relative? Age of time of diagnosis? Genetic Ethnic Background/Ancestry (i.e. Irish, Scottish, Middle Eastern, etc.
7 Symptom Review: Circle the symptoms that you are experiencing. General Weight change Fever Fatigue Chills Night sweats Appetite change Sleep problems Skin Itching Rash Mole change Hair change Color change Non-healing sores Eyes Vision change Double vision Pain Spots / Floaters Itching Watering Redness Ears Ear pain Hearing loss Use of hearing aid Ringing in ears Nose Nose bleeds Congestion Runny nose Itching Sinus problems Mouth, Throat Teeth problems Mouth sores Sore throat Difficulty swallowing Hoarseness Neck Lump Swollen glands Pain Breasts Lump Pain Nipple discharge Lungs Cough Wheeze Shortness of breath Sputum Coughing up blood Heart/Vessels Chest pain Swelling feet/legs Palpitations Murmur Calf pain with - walking Varicose veins Easy bruising / bleeding Stomach Heartburn Nausea / Vomiting -Diarrhea Constipation Bowel changes Bloody stools Black stools Abdominal pain Excessive -gas/belching Hemorrhoids Urinary Burning Frequent urination Painful urination Blood in urine Reduced urine flow Hesitancy Dribbling Wake up to urinate Incontinence Muscle/Skeleton Joint pain Joint swelling Joint redness Neck pain Back pain Muscle pain Neurological Paralysis Seizures Fainting Muscle weakness Balance problems Coordination problems Numbness Tremors Memory changes Headache Female Reproductive Abnormal vaginal bleeding Vaginal discharge Vaginal dryness Vaginal itching Painful intercourse Painful periods Irregular periods PMS Hot flashes / Night sweats Problems with sex Genital sores (G: P: AB: SAB: LC: ) Male Reproductive Discharge from penis Sores on penis Testicular pain Testicular lump Problems with sex Erection problems Prostate problems Emotional Depression Trouble sleeping Nervousness Anxiety Stress Trouble concentrating
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