Patient Intake Form - Barrie South Walkin Clinic

First Name

Middle Name

Last Name

Date of Birth

Patient Age

Patient Gender

Phone no.

Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Health Card Province:

Health Card Number:

Version Code (For Ontario OHIP, 2 Letters, required if applicable ) :

Expiry Date (Health Card)

Do you have a Family Health Doctor?

Yes

Previous Family Doctor:

Emergency Contact Name

Emergency Contact Number

Marital Status

Name of Spouse

Race/ Ethnicity

Do you smoke?

Never

In the past

Yes I do smoke

Do you consume alcohol?

Never

In the past

Yes I do

Cannabis/ CBD

Never

In the past

Yes I do

Gambling?

Never

Rarely

Often

Do you workout/ exercise?

Yes

How many times a week? Minutes in total?

Highest level of Education

Your Occupation

Has a male member of your family under the age of 55 had a stroke or a heart attack?

Yes

Has a female member of your family under the age of 55 had a stroke or a heart attack?

Yes

Age of your mother? (If deceased, kindly provide their age at the time of passing?)

Health Issues of your mother (if any)?

Age of your father? (If deceased, kindly provide their age at the time of passing?)

Health Issues of your father (if any)?

Sisters

Column 1

Brothers

Column 1

I am adopted and do not know my biological family history

Yes

Does any of your close relatives have any of the following conditions (parents, grandparents, siblings, aunts/uncles)?

High Blood Pressure

Thyroid Disease

Breast Cancer

Ovarian Cancer

Mental Health

Heart Disease

Asthma

Parkinsons

Dementia/ Alzheimer's

IBS

Stroke

Osteoporosis

Prostate Cancer

Addictions

Auto Immune

Please check all that apply and add details if possible. Example: dates/hospital/surgeon

Appendix removed

Bowel surgery

Gallbladder surgery

Hernia repair

Hemorrhoids

C-section

Tubes tied/remove

Ectopic Pregnancy

Endometriosis

Ovary Removed/Ovarian cyst

Bladder/Kidney or Prostate

Heart Surgery

Lung Surgery

Nose surgery

Cancer

Tonsillectomy

Ear surgery

Thyroid

Eyes

Back/Spine

Joint Replacement

Other joint/bone/ligament. (ie fractures, ACL, etc.)

Gastroscopy

Yes

Date / Time

Colonoscopy

Yes

Date / Time

Medical History: Please check the boxes

Blood Sugar

Diabetes

Borderline Diabetes

Low Blood sugar

Brain

Stroke

Mini stroke/TIA

Seizures/ Epilepsy

Migraines

Chronic headaches

Dementia

Others

Liver/ Gallbladder

Hepatitis

Fatty Liver

Cirrhosis

Gallstones

Others

Sleep

Sleep apnea

Insomnia

Others

Mental Health

Anxiety

Depression

Bipolar

Schizophrenia

ADHD

Fetal alcohol syndrome

Addictions

Others

Blood Pressure

High Blood pressure

Low Blood Pressure

Ears

Hearing impairment

Others

Eyes

Vision impairment

Glaucoma

Macular degeneration

Others

Kidney

Impaired function

kidney stones

Others

Joints

Osteoarthritis

Gout

Rheumatoid arthritis

Lupus

Others

Skin

Eczema

Acne

Psoriasis

Rosacea

Hives

Others

Lung Problems

Asthma

COPD

Emphysema

Pneumonia

Others

Nose

Chronic stuffy

Runny nose

Seasonal allergies

Others

Bladder

Bladder infections

Urination issues

Others

Thyroid

Underactive “hypo”

Overactive “hyper”

Nodules

Grave disease

Hashimoto's

Others

Infections

HIV

Chlamydia

Genital herpes

HPV

Gonorrhea

Heart Issues

Heart attack

Heart failure

Chest pain/Angina

Heart valve disease

Atrial fibrillation

Abnormal rhythm

Others

Mouth / Throat

Dentures

Thyroid

Others

Stomach/ Bowels

Constipation

Diverticulosis/ itis

Colon polyps

IBS

Crohn's/ ulcerative colitis

Hernias

Hemorrhoids

Celiac disease

Others

Sexual orientation

Heterosexual

Homosexual

Bisexual

Prefer not to say

Sexual orientation

Heterosexual

Homosexual

Bisexual

Prefer not to say

Female Health:

Age periods started

Age of Menopause

Last regular period

Menstrual Periods

Regular

Irregular

Heavy Flow Painful

Current Birth Control

Pill

Patch

Vaginal ring

Copper |UD

Hormone IUD

Depo

Implant

Condoms

Calendar

Tubes tied

Partner vasectomy

Pregnancies:

Currently Pregnant? Weeks?

Number of live births

Number of still births

Number of miscarriages

Ectopic/tubal pregnancy

Number of abortions

Others, please check the box

Abnormal Pap test(s)

Polycystic Ovaries

Endometriosis

Infertility

Others

Male Health

Please check the box

Erectile dysfunction

Premature ejaculation

Prostatitis

Low testosterone

Genital problems

Enlarged prostate

Transgender health

Please check the box

Hormone therapy

Reassignment surgery

If possible, please obtain a meds list from your pharmacy if possible.

Please list all medications, vitamins, drops, supplements and inhalers that you take regularly and occasionally.

Vaccinations: Please indicate whether you have had each vaccine

Flu Shot

Pneumonia Shot

Shingles

Tetanus

Hepatitis A/B

Covid

Did you receive all of the routine childhood vaccines?

Yes

Other vaccinations:

Do you consent to receive text/email notifications?

Yes

Do you consent to a family member making appointments, receiving test results or appointment information on your behalf?

Yes

Name of authorized family member

Number of authorized family member

Are you currently enrolled with another family doctor in Ontario?

Yes

Name of the family doctor

Patient Signature (Type in your Name to confirm)

Guardian name

Guardian Signature (Type in your Name to confirm)

Date of Signature

Relationship to patient: