New Patient Intake Form

Please complete the information below as accurately as possible. All sections are important. If a question does not apply to you, enter “None” or “Not Applicable”.

Patient Information

Tell us a little about yourself.

Legal Name *

Preferred Name

Date of Birth *

Gender *

PHN Province *

Personal Health Number (PHN) *

Email Address *

Date

Street Address

City

Postal Code

Preferred Pharmacy

Previous Family Physician

Reason for seeking a new family physician

Do you have a family member currently attending this clinic?

YesNo

Family Member Name and Relationship

Contact Information

Please provide all applicable phone numbers.

Home Phone

Cell Phone

Work Phone

Emergency Contact

Name

Relationship

Phone Number

Medications & Allergies

Please include prescription and non-prescription items.

Current Medications

Include prescriptions, vitamins and supplements.

Allergies

Include medication, food and environmental allergies.

Weight

Height

Women's Health

Complete where applicable.

Not Applicable

Pregnancies

Live Births

Miscarriages

Last Menstrual Period

Personal & Social History

Information about your current lifestyle and employment.

Occupation

Student / School

Marital Status

Unemployed / Disabled / Disability Benefits

Retired — Previous Occupation

Smoking & Alcohol

Please provide information about current or previous use.

Smoking

Do you currently smoke?

Approximately how many cigarettes per day?

If you previously smoked, when did you quit?

Alcohol

Do you currently consume alcohol?

Approximately how much?

If you previously consumed alcohol, when did you quit?

Preventive Screening

Select completed tests and provide the approximate year.

Mammogram (Ages 40–74)

FIT Test (Ages 50–74)

PAP (Ages 25–69)

Colonoscopy

Lung Cancer Screening / CT

Bone Mass Density

Last Labs

Insurance Claims

ICBC / WorkSafeBC

Active Claims

Please provide information about any active claim and the year of the claim.