New Patient Intake Form Name(Required) First Last Email(Required) Date of Birth(Required) MM slash DD slash YYYY Gender(Required) Previous Physician(Required) Phone(Required)Marital Status(Required) Married Common Law Single Separated Divorced Widowed Children?(Required) Yes No How many at home?(Required) Occupation(Required) Healthcard #(Required) Pharmacy Emergency ContactName(Required) First Last Phone(Required)Relationship(Required) Medical HistoryHave you ever experienced any of the following?(Required) High Cholesteral High Blood Pressure Diabetes Heart Attack/Heart Disease Depression Anxiety Other Mental Problems Gout Seizures/Epilepsy Joint Pain Osteoporosis Asthma/COPD Other Please list any past or present medical problems below (check all that apply or click "Other" to write down any others not listed).Medical History Not Listed Surgical History(Required) Add RemovePress the plus button on the right to add a new line.Family History(Required) Add RemovePress the plus button on the right to add a new line.Current Medications(Required) Add RemovePress the plus button on the right to add a new line.Do you smoke?(Required) Yes No Quit How Many Per Day?(Required) How Many Years?(Required) When did you quit?(Required) Do you have allergies?(Required) Yes No What allergies do you have?(Required) How often do you have allergic reactions?(Required) Daily Weekly Monthly Do You Consume Alcohol Regularly?(Required) Yes No How often do you consume alcohol?(Required) Daily Weekly Monthly Do You Use Recreational Drugs?(Required) Yes No Discuss with Doctor Have you had an influenza vaccine in the last year?(Required) Yes No Date(Required) MM slash DD slash YYYY Rough month and year.Have you had an Covid vaccine in the last year?(Required) Yes No Date(Required) MM slash DD slash YYYY Rough month and year.Anything the Doctor Should Be Made Aware Of?(Required)CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
