Health History

In addition to completing the patient registration form, complete the health history form if you need a family physician.

Patient Name *

First

Last

Email *

Please enter your email, so we can follow up with you.

Phone number *

Preferred Contact Number *

Pharmacy

Family Practitioner

Next of Kin *

Next of Kin (Phone number & Email) *

Medical History and Condition

Surgical History

Medications

Allergies and Intolerances

Lifestyles

Marital Status

Number of children

Occupation

Smoking status

Caffeine: cups per day

Exercise

Recreational drug use

Alcohol Consumption (drink/week):

Family History

Immunization and year (if known)

Signature *

Please fill in your name to digitally sign this document

Date *