Application Form - The Medi Collective

All of your responses to these questions are important to understand your specific health problems. They are strictly confidential and will never be disclosed to anyone under any circumstances without your written permission.

Please check the appropriate response or fill in the blank

Full Name*

Date of Birth*

Email*

Phone number

Do you have any problems with your balance?

Yes No

Do you have any problems with headache?

Yes No

Do you have any problems with vour eyes or vision?

Yes No

Do you wear glasses

Yes No

When was your vision last tested?

Yes No

Did you require a change in your lens prescription at that time?

Yes No

Do you have any problems with your ears or hearing (including ringing or other noises, a sense of fullness in the ears, or pain)?

Yes No

Do you have any problems with your nose (including congestion, runny nose, nosebleeds. or earn over your sinuses?

Yes No

Do you have any problems with your mouth or teeth (including sores in the mouth, dental cavities or bleeding gums)?

Yes No

Do you wear dentures?

Yes No

Have you noticed any recent chances in your voice or a hoarse voice?

Yes No

Do you have any problems with a cough?

Yes No

If yes

Do you cough up any sputum or phlegm? Do you cough up any blood?

Do you have a problem with feeling hotter or colder than most people (including excessive sweating?)

Yes No

Have you gained or lost any weight recently?

Yes No

Have you had any change in your appetite (increase or decrease)?

Yes No

Have you noticed excessive thirst recently?

Yes No

Do you ever get short of breath when you lie flat on your back?

Yes No

Do you ever wake up during the night short of breath?

Yes No

Do you have problems with shortness of breath?

Yes No

Do you have fainting spells, blackouts, or light-headed episodes?

Yes No

Do you ever have swelling of the ankles?

Yes No

Do you ever notice a heaviness or tightness in your chest that is brought on by exertion (such as walking quickly or going upstairs) and is relieved by resting?

Yes No

Do you ever notice your heart skipped a beat or beating irregularly?

Yes No

Do you have pains in your legs when you walk?

Yes No

Do you have any problems swallowing?

Yes No

Do you have any problems with heartburn?

Yes No

Do you have any problems with nausea (upset stomach) or vomiting?

Yes No

Do you have any pains in your stomach or abdomen?

Yes No

Have you noticed any change in your bowel movements recently (including diarrhea, constipation, black colour, or blood)?

Yes No

Do you have a problem with pains in your neck?

Yes No

Do you have pains in our back (especially the lower back)?

Yes No

Do you have any problems with your arms or legs (including pain, weakness, numbness, tingling, or tremors)?

Yes No

Do you have any problems with your joints?

Yes No

Have you noticed any spots, lumps, or rashes appearing on your skin lately, or changes in appearance of any existing rash or spot?

Yes No

Have you noticed any recent changes in skin colour?

Yes No

Have you had any problems with itchy skin recently?

Yes No

have you noticed any problems with your sleep recently?

Yes No

Have you had a fever, chills, or night sweats recently?

Yes No

Have you recently been feeling tired most of the time?

Yes No

Have you had problems with nervousness, tension, or anxiety recently?

Yes No

Have you been feeling depressed lately?

Yes No

Have you noticed any problems with your memory or concentration lately?

Yes No

Do you notice that you bruise easily, or have problems with persistent or continued bleeding of cuts or wounds?

Yes No

Do you have problems urinating (including pain, burning, urgent need to urinate, or excessive or frequent urinating)?

Yes No

Do you have blood in your urine, or brown coloured urine?

Yes No

Do you have problems with your sexual drive or sexual relationship?

Yes No

Do you have concerns regarding contraception(birth control) or fertility?

Yes No

Do you use anything for contraception?

Yes No

If yes what?

WOMEN ONLY

Do you spill or dribble your urine when you cough or sneeze?

Yes No

Do you have any problems with your menstrual periods (including irregular or heavy periods, bleeding between periods, pain or cramping)?

Yes No

Do you have a problem with vaginal itching, discharge, soreness, or sores or warts in your genital area?

Yes No

Do you have any sexual problems (such as difficulty having orgasms, pain or bleeding with intercourse?

Yes No

Do you have problems with your breasts (including pain, soreness, discharge or bleeding from the nipples, or lumps in your breasts?

Yes No

Have you reached menopause?

Yes No

If yes, are you on hormone replacement therapy?

Yes No

MEN ONLY

Do you have any problems starting to urinate, getting a good stream, or dribbling after urinating?

Yes No

Have you noticed a discharge from your penis, or sores or warts in your genital area?

Yes No

Do you have any sexual problems (such as getting or maintaining an erection, ejaculation, or other problems)?

Yes No

Have you noticed any pain or swelling in your testicles?

Yes No

MEDICATION AND ALLERGIES

Are you allergic to any medicine?

Yes No

If Yes, please list and describe your reaction to it

Do you have any other allergies (including food, pollen, or hayfever)?

Yes No

If Yes, please list and describe your reaction to it

Are you on any medication?

Yes No

If Yes, please list the Medicine, Dose, and When they were taken

PAST HISTORY

Have you had any operations in the past?

Yes No

If Yes, please list the surgery, when it was, and were there any complications?

Have you ever had a bad reaction to an anesthetic?

Yes No

If yes, please describe your reaction:

Other than your operations have you ever been hospitalized or had any serious illnesses?

Yes No

If yes, please list diagnosis, and when it occurred:

How many pregnancies have you had in total (including present)?

How many pregnancies ended in a premature baby? (a premature birth is more than 3 weeks before your due date)

How many pregnancies ended in a full term baby?

How many pregnancies ended in abortion or miscarriages?

How many of your children are alive today?

How many pregnancies ended in stillbirth?

Have you ever had a C-Section (Caesarean Section)?

Yes No

FAMILY HISTORY

Do any of your blood relatives have any of the following diseases? If Yes, please write their relationship to you

Yes No

Heart disease

Hypertension (high blood pressure)

Epilepsy (seizures)

Psychiatric disorders (mental illness)

Diabetes

Rheumatoid arthritis

Stroke

Tuberculosis (TB)

Thyroid disease

Glaucoma

Breast cancer

Serious kidney problems

Serious reactions to anesthetics

Bowel cancer

Osteoporosis

Any other inherited disorder

PERSONAL/SOCIAL HISTORY

Are you single, married, common-law separated, divorced, or widowed?

Single Married Common-law separated Divorced Widowed

Are you concerned about your marriage or relationship?

Yes No

How many children do you have?

What are their sexes and ages?

How many children live at home with you?

Does anyone else live in your home?

What is your job?

What is your spouse's job?

How much alcohol do you drink each week (including beer, wine and liquor)?

Do you smoke?

Yes No

If yes, for how many year have you smoked? How many cigarettes per day?

If you have quit, how many years ago?

Do you take street drugs?

Yes No

If so, what do you take?

Are you:

heterosexual (straight) homosexual (gay) bisexual (sex with both sexes)

Do you exercise regularly?

Yes No

If so, what, how often and for how long?

Do you take any vitamins?

Yes No

If so, what do you take?

When was your last immunization (especially tetanus)?

Is there anything that you are concerned about, and would like to discuss with the Doctor? (Please write a few words about your concern or problems in the designated space below)

Etobicoke, On

London, On

Kitchener, On

Etobicoke, On

London, On

Kitchener, On

Please check the appropriate response or fill in the blank

WOMEN ONLY

MEN ONLY

MEDICATION AND ALLERGIES

PAST HISTORY

FAMILY HISTORY

PERSONAL/SOCIAL HISTORY