DEMOGRAPHICS
Patient's Name:(Last) (First) (Middle)
Sex: Female Male Date of Birth (mm/dd/yy):
OHIP Number: - - - (please include two-letter version code)
Marital Status: Married Single Common Law Divorced Widowed
Address: Postal Code:
Phone numbers:Home WORK
Cell Other
Email address: May we correspond via email? Yes No
Emergency Contact Name: Phone number:
Relationship to you:
Employment Status: Employed Student Retired Unemployed Self-employed
Employer: Occupation:
Highest level of Education: High School College University Post-graduate Studies
I am on ODSP I am on Ontario Works I have private insurance for medications and benefits
Have you registered with Health Care Connect? Yes No


SOCIAL HISTORY
Smoking history: Never smoked Current smoker - # packs/day Year started smoking
Ex-smoker - year quit Used to smoke packs/day x years Alcohol: # drinks/week
Recreational street drugs? No Yes - please specify:


ALLERGIES
Do you have environmental allergies (e.g. Grass, Pollen, Mold, Pets)? Yes: No
Do you have allergies to medical products (e.g. IV contrast, Latex)? Yes: No
Do you have allergies to any medications? Yes No If yes, please list medications and reactions:


CURRENT MEDICAL CONDITIONS
ConditionYesNoUnsureDetails
High blood pressure
High cholesterol
Heart disease/Heart attack
Diabetes
Kidney disease
Heartburn/acid reflux/ulcers
Liver disease
Stroke/TIA
Migraine/recurrent headaches
Epilepsy/seizures
Thyroid disease
Bleeding disorders
Clotting disorders
Anemia (B12, iron, thalassemia)
Dementia
Hearing problems
Depression
Anxiety
Psychiatric problems - specify
Alcoholism
Drug addiction
Chronic pain
Arthritis - specify type and joints
Gout
Sleep apnea
Asthma
COPD
Other lung disease - specify
Hepatitis A, B, or C
HIV/AIDS
Sexually transmitted infections - specify
Eye condition - specify
Other:


PAST MEDICAL HISTORY
Surgeries and Procedures
1) Date
2) Date
3) Date
4) Date
5) Date
Past Medical Conditions or Major Injuries
1) Date
2) Date
3) Date
4) Date
5) Date


FAMILY HISTORY
Were any of your parents or siblings diagnosed with heart disease before age 60? Yes No
Were any of your parents or siblings diagnosed with colon/rectal cancer? Yes - at age No
Were any of your parents or siblings diagnosed with breast cancer? Yes - at age No
Were any of your parents or siblings diagnosed with prostate cancer? Yes - at age No
Please list any other pertinent family history:
Condition: Relative:
Condition: Relative:
Condition: Relative:
Condition: Relative:

CURRENT MEDICATIONS
Pharmacy name:Tel #: Fax #:
Please list prescribed and over-the-counter medications, vitamins, and supplements you take regularly:
Name of MedicationDose and Frequency
(e.g. 2 mg twice a day)
Purpose
Proceed

Please enter the first and last name of the friend or family member who referred you to our clinic.

Please enter your postal code.