new Patient Intake Form Please complete and submit the following form if you’re interested in becoming a patient at our family practice. Patient Information Name * First Name Last Name Previous Family Physician PHN Personal Health Number Date of Birth MM DD YYYY Address Phone Number (###) ### #### Email * Patient consents to receive email/texts Yes No Emergency Contact Information Name First Name Last Name Relation Contact Number (###) ### #### Medical History Past Medical History including surgeries, procedures, dates, etc. Family History Please indicate any significant medical issues among family members and who they affect (e.g. Diabetes, Cancer, high blood pressure, heart attack, stroke, lung disease, etc) Preventative Health & Lifestyle Do you smoke? Yes No Do you use recreational drugs? Yes No Do you exercise regularly? Yes No If yes, describe: Do you drink alcohol? Socially Regularly Never Family Dependents Education/Occupation Hobbies/Interests Religion/Faith Prescription Medications Non-Prescription Medications over-the-counter, herbal, vitamins, other Allergies (and reactions) When did you last have the following: Pap Smear Mammogram Hemoccult-FIT (stool test for colon cancer screen) Colonoscopy Prostate Exam Complete Physical Flu Vaccine Pneumonia Vaccine Tetanus Vaccine HPV Vaccine Shingles Vaccine Hepatitis A Vaccine Hepatitis B Vaccine Other Thank you for your interest in our practice. We will be in touch regarding next steps.
