Patient Profile Female Patient Profile Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDate of Birth *Day Month YearCareCard Number (PHN) *Email Address *Primary Contact Number *Address *Family Doctor *Enter your family doctor’s name, address and contact number (or NONE)Marital status *Never marriedMarriedCommon lawSeparatedDivorcedWidowedAllergies or side effects to medications *Enter names of medications and the reactions you had (or NONE)Name of Pharmacy *Pharmacy Name and City of Pharmacy (or NONE)Current prescription medications *Enter names of medications, strengths and frequencies (or NONE)Current non-prescription drugsEnter your over-the-counter drugs, vitamins, herbs, etc.CURRENT MEDICAL HISTORYPlease share your current medical history below:Medical conditions ie Diabetic, Hypertension, etc… *Enter your conditions (or NONE) – This is not the reason for the appointmentPAST MEDICAL HISTORYPlease share your past medical history below:Heart disease *Age of onsetHypertension *Age of onsetHigh cholesterol *Age of onsetDiabetes *Age of onsetAsthma *Age of onsetStroke *Age of onsetDementia/Alzheimer's *Age of onsetOsteoporosis *Age of onsetPsychiatric problem *Age of onsetCancer (indicate type) *Age of onsetOtherAge of onsetOperations/ProceduresEnter types of operations or procedures (e.g. colonoscopy), the reasons and yearsHospitalizationsEnter names of hospitals, the reasons for admission and yearsMajor past problems/injuries *Enter descriptions of problems or injuries, the outcomes and yearsFAMILY MEDICAL HISTORYPlease indicate the relationship (state paternal or maternal) and approximate age of onset for blood relatives with any of the following conditions:High cholesterolRelationship and age of onsetHeart diseaseRelationship and age of onsetHypertensionRelationship and age of onsetDiabetesRelationship and age of onsetAsthmaRelationship and age of onsetStrokeRelationship and age of onsetDementia/Alzheimer'sRelationship and age of onsetOsteoporosisRelationship and age of onsetPsychiatric problemRelationship and age of onsetCancer (indicate type)Relationship and age of onsetOtherRelationship and age of onsetSOCIAL HISTORYPlease share your social history below:Exercise *Enter what exercise you do, how often, and how long each time (or NONE)Smoking *Indicate your status below, and if you are or were a smoker then enter here the number of times per day, number of years and year stopped if applicableSmoking status *Never smokedSmokerEx-smokerPassive smoke contactVaping *Indicate your status below, and if you are or were a vaper then enter here the number of times per day, number of years and year stopped if applicableVaping status *Never vapedVaperEx-vaperPassive vapor contactAlcohol *Indicate your drinking habits below, and if you are an ex-drinker enter here the year you stoppedWhat best describes your drinking habits? *No alchoholLight drinkerModerate drinkerHeavy drinkerEx-drinkerDrinks per day on average Drinks per day on average: 0 Drinking days per week on average Drinking days per week on average: 0 Street drugsIndicate your drug habits below, and if you have ever used drugs enter here what drugs, how often and when last usedWhat best describes your recreational drug use? *Never used drugsEx-userLight userModerate userHeavy userObstetrical historyEnter any obstetrical complications here, and the number of obstetrical events belowPregnancies Pregnancies: 0 Term deliveries Term deliveries: 0 Preterm deliveries Preterm deliveries: 0 Miscarriages Miscarriages: 0 Pregnancy terminations Pregnancy terminations: 0 Living Living: 0 Occupation *Enter your occupation or one of the following: Student, Retired, Disability, Social assistaceRecreation/Hobbies *Enter your pastimes (or NONE)Are your childhood immunizations up to date *Have you ever had Chickenpox? *YesNoUnsureImmunizationsTetanusFluCovid 19PrevnarPneumovaxHepatitis AHepatitis BShinglesHPV*Tetanus: Date of vaccination *Day Month Year*Flu: Year of last vaccination *Year*Covid19: Date of first dose *Day Month Year*Covid19: Date of most recent dose *Day Month YearPREVENTION AND WELLNESSPlease share your screening tests below:Women under 70: Date of last papMonth YearWomen over 50: Date of last mammogramMonth YearWomen over 50: Date of last stool test for cancerMonth YearSubmit this form Patient Profile for MalesPlease enable JavaScript in your browser to complete this form.Name *FirstMiddleLastDate of Birth *Day Month YearCareCard Number (PHN) *Email Address *Primary Contact Number *Address *Family Doctor *Enter your family doctor’s name, address and contact number (or NONE)Marital status *Never marriedMarriedCommon lawSeparatedDivorcedWidowedAllergies or side effects to medications *Enter names of medications and the reactions you had (or NONE)Name of Pharmacy *Pharmacy Name and City of Pharmacy (or NONE)Current prescription medications *Enter names of medications, strengths and frequencies (or NONE)Current non-prescription drugsEnter your over-the-counter drugs, vitamins, herbs, etc.CURRENT MEDICAL HISTORYPlease share your current medical history below:Medical conditions ie Diabetic, Hypertension, etc… *Enter your conditions (or NONE) – This is not the reason for the appointmentPAST MEDICAL HISTORYPlease share your past medical history below:Heart disease *Age of onsetHypertension *Age of onsetHigh cholesterol *Age of onsetDiabetes *Age of onsetAsthma *Age of onsetStroke *Age of onsetDementia/Alzheimer's *Age of onsetOsteoporosis *Age of onsetPsychiatric problem *Age of onsetCancer (indicate type) *Age of onsetOtherAge of onsetOperations/ProceduresEnter types of operations or procedures (e.g. colonoscopy), the reasons and yearsHospitalizationsEnter names of hospitals, the reasons for admission and yearsMajor past problems/injuries *Enter descriptions of problems or injuries, the outcomes and yearsFAMILY MEDICAL HISTORYPlease indicate the relationship (state paternal or maternal) and approximate age of onset for blood relatives with any of the following conditions:High cholesterolRelationship and age of onsetHeart diseaseRelationship and age of onsetHypertensionRelationship and age of onsetDiabetesRelationship and age of onsetAsthmaRelationship and age of onsetStrokeRelationship and age of onsetDementia/Alzheimer'sRelationship and age of onsetOsteoporosisRelationship and age of onsetPsychiatric problemRelationship and age of onsetCancer (indicate type)Relationship and age of onsetOtherRelationship and age of onsetSOCIAL HISTORYPlease share your social history below:Exercise *Enter what exercise you do, how often, and how long each time (or NONE)Smoking *Indicate your status below, and if you are or were a smoker then enter here the number of times per day, number of years and year stopped if applicableSmoking status *Never smokedSmokerEx-smokerPassive smoke contactVaping *Indicate your status below, and if you are or were a vaper then enter here the number of times per day, number of years and year stopped if applicableVaping status *Never vapedVaperEx-vaperPassive vapor contactAlcohol *Indicate your drinking habits below, and if you are an ex-drinker enter here the year you stoppedWhat best describes your drinking habits? *No alchoholLight drinkerModerate drinkerHeavy drinkerEx-drinkerDrinks per day on average Drinks per day on average: 0 Drinking days per week on average Drinking days per week on average: 0 Street drugsIndicate your drug habits below, and if you have ever used drugs enter here what drugs, how often and when last usedWhat best describes your recreational drug use? *Never used drugsEx-userLight userModerate userHeavy userOccupation *Enter your occupation or one of the following: Student, Retired, Disability, Social assistaceRecreation/Hobbies *Enter your pastimes (or NONE)Are your childhood immunizations up to date *Have you ever had Chickenpox? *YesNoUnsureImmunizationsTetanusFluCovid 19PrevnarPneumovaxHepatitis AHepatitis BShinglesHPV*Tetanus: Date of vaccination *Day Month Year*Flu: Year of last vaccination *Year*Covid19: Date of first dose *Day Month Year*Covid19: Date of most recent dose *Day Month YearPREVENTION AND WELLNESSPlease share your screening tests below:Men over 50: Date of last stool test for cancerMonth YearSubmit this form