Welcome to the Patient Questionnaire For Your Appointment With Dr. Hajiazim
*All information on this form is strictly confidential*
Our Questionnaire may seem long, but most of the questions require only a check, so it will go quickly.
Estimated completion time is 10 minutes
You may need to ask family members about family history, please do so.
It is our belief that the information you provide will help us assess and treat you better.
If you are unable to answer a question, please proceed without answering unless it is a required field.
If you have any questions, please contact us.
Thank you!
