Final Questionnaire

1
Today's Date (HIDDEN)
2
Patient ID (HIDDEN)
3
Name.* This field is required.Please provide your full name. Middle Name is an optional field. If you don't have a last name, please fill both First And Last Name boxes with same name.
First Name
Middle Name
Last Name
4
Sex.* This field is required.
Male
Female
Other
5
Phone Number.* This field is required.Provide the same phone number as your call back number.
6
Email.* This field is required.Please provide your personal and private email address.
example@example.com
7
Date Of Birth.* This field is required.Please use select your date of birth from the calendar below.
Date
Day
Month
Year
8
Height (In cm)* This field is required.
9
Weight (In Pounds).* This field is required.
10
Home Address.* This field is required.Enter your full home address.
Street Address
Street Address Line 2
City
State
Zip Code
Canada
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Occupation.Example: Student / Employment / Retired, Benefits At Work (Company Name).
12
Do You Have Extended Benefits From Work?
YESNO
13
What Is the Name Of Your Insurance Provider?
14
Which Pharmacy Do You Use To Pickup Your Prescriptions?* This field is required.
Medical Building Pharmacy At 21 Queensway West, Mississauga (Free Home Delivery Available).
Other Pharmacy.
15
Provide Name Of Your Pharmacy.* This field is required.Type the full name of your pharmacy.
16
Please Provide The Fax Number Of Your Pharmacy.* This field is required.
17
Do You Know The Address Of Your Pharmacy?* This field is required.
YESNO
18
Please Provide The Address Of Your Pharmacy.Enter Full Address.
Street Address
Street Address Line 2
City
State
Zip Code
Canada
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
Do You Have Any Allergies To Medication?* This field is required.
YESNO
20
Please Provide More Details On Your Allergies.* This field is required.Example: Drug 1 Name: Type Of Reaction, Drug 2 Name: Type Of Reaction, etc.
21
Are You Currently Taking Any Medication(s)?* This field is required.
YESNO
22
Provide Name Of Medication, Dosage And Times Taken Per Day.* This field is required.
23
Are You A Cigarette Smoker?
YESNO
24
How Many Cigarettes Do You Smoke In A Day?
Half A Pack
1 Pack
2 Pack
3 Pack
Other
25
Do You Consume Alcohol?
YESNO
26
How Many Glasses Of Alcoholic Beverages Do You Consume In A Day?
1 Glass Of Wine/Beer Or Hard Liquor Per Day
2 Glass Of Wine/Beer Or Hard Liquor Per Day
4 Glass Of Wine/Beer Or Hard Liquor Per Day
8 Glass Of Wine/Beer Or Hard Liquor Per Day
Other
27
Do You Have Any Medical Problems?* This field is required.
YESNO
28
Do You Have Any Heart Problems?Heart issues include: High Cholesterol, High Blood Pressure, Heart Attacks, Angina, etc.
YESNO
29
Please Select One And / Or More Options With Respect To Your Heart Problem.
Blood Pressure
Cholesterol
Angina/Heart Attack
Rhythm Problems
Other
30
Do You Have Any Breathing/Lung Problems?Do you have Asthma Or Other? Do You Smoke?
YESNO
31
Please Select One And / Or More Options With Respect To Your Breathing/Lung Problem.
Asthma
Emphysema
Chronic Bronchitis
Use A CPAP Machine
Other
32
Do You Have Any Stomach Problems?Wear Glasses? Other Eye Problems.
YESNO
33
Please Select One And / Or More Options With Respect To Your Stomach Problem.
Reflux
Stomach Ulcer
IBS
Other
34
Do You Have Any Liver Problems?
YESNO
35
Please Select One And / Or More Options With Respect To Your Liver Problem.
Viral Hepatitis A/B/C
Alcoholic Hepatitis
Gall Stones
Other
36
Do You Have Any Bowel Problems?
YESNO
37
Please Select One And / Or More Options With Respect To Your Bowel Problem.
Ulcerative Colitis
Chrons Disease
Irritable Bowels
Food Allergies
Other
38
Do You Have Any Pancreas Problems?
YESNO
39
Please Select One And / Or More Options With Respect To Your Pancreas Problem.
Alcoholic Pancreatitis
Other
40
Do You Have Any Kidney Problems?
YESNO
41
Do You Have Any Genital Or Urinary Problems? (Male)
YESNO
42
Please Select One And / Or More Options With Respect To Your Genital Or Urinary Problem.
Erectile Dysfunction (ED)
Prostate Problems
STD
Other
43
Do You Have Any Genital/Urinary/Reproductive Problems? (Female)
YESNO
44
Please Select One And / Or More Options With Respect To Your Genital/Urinary/Reproductive Problem.
User Of BCP
Use IUD
Problems With Periods (Heavy Or Painful)
Menopause
Other
45
Do You Have Any Neck, Spine, Joint Or Limb Pain/Problems?
YESNO
46
Please Select One And / Or More Options With Respect To Your Neck, Spine, Joint Or Limb Problem.
Neck Pain
Lower Back Pain
Hips Problems
Knee
Foot
Shoulder
Elbow
Other
47
Have You Had A Bone Density Exam?If you are over 55 years old, then answer the question please.
No
Yes
I Don't Know What This Is
48
When Was Your Last Bone Density Exam Done?
Less Than 1 Year.
1-2 Years.
More Than 3 Years.
I Don't Remember.
49
Are You Taking Vitamin D And/Or Calcium Supplements?
YESNO
50
Do You Have Any Skin Problems?
YESNO
51
Please Select One And / Or More Options With Respect To Your Skin Problem.
Eczema
Acne
Other
52
Do You Have Any Vision Problems?
YESNO
53
Do You Wear Glasses Or Contacts?
YESNO
54
When Was Your Last Vision Test?Example: June 2022. If you don't remember, you may leave this blank.
55
Do You Have Any Hearing Problems?Any Problems Such As Requiring Hearing Aids, Wax Build Up, Deafness, Dizziness (Vertigo) etc.
YESNO
56
Please Provide Details On Your Hearing Problems.
57
Do You Wear A Hearing Aid?
YESNO
58
Do You Have Any Nasal Problems?
YESNO
59
Please Select One And / Or More Options With Respect To Your Nasal Problem.
Environmental allergies
Other
60
Do You Have Any Neurological (Nerve) Problems?Examples Include: Headaches, Seizures, Other etc.
YESNO
61
Please Select One And / Or More Options With Respect To Your Neurological (Nerve) Problem.
Tension Headaches
Migrane Headaches
Seizures
Other
62
Do You Have Any Emotional Disorder(s)?Examples Include: Anxiety, Stress, Sleeping Problems, Depression, etc.
YESNO
63
Please Select One And / Or More Options With Respect To Your Emotional Problem.
Anxiety/Stress
Depression
Manic Depressive
Other
64
Do You Have Diabetes?
YESNO
65
Please Select One And / Or More Options With Respect To Your Diabetes Problem.
On Diet & Weight Control Only
On Oral Medication
On Insulin
66
Do You Have Any Thyroid Problems?
YESNO
67
Please Select One And / Or More Options With Respect To Your Thyroid Problem.
Hypothyroidism (Low Thyroid Levels)
Hyperthyroidism
Other
68
Do You Have Regular Annual Health Exams (Including The Recommended Blood Test, X-rays, Mammograms, Bone Density)?
YESNO
69
When Was The Last Time You Did An Annual Heath Exam?
< 1 Year
1 Year Ago
2 Years Ago
3 Years Ago
70
Are You Up To Date On Your Publicly Funded Vaccines?
YESNO
71
Would You Like To Discuss Any Lifestyle Or Habitual Concerns With A Doctor On A Future Follow-Up Call?Please select a topic that applies to you
Smoking Cessation.
Obesity.
Diet Issues.
Alcohol/Substance Use.
Stress/Anxiety/Depression Issues.
Sleeping Disorders.
Immunizations/Vaccinations.
Annual Health Exam.
Allergies.
None Of The Following.
Other
72
Is It Your First Time Using Our Facility?
First Time Visiting In-person Or Telemedicine (Virtual Care).
I Have Been To The Clinic As A Patient Before.
73
How Did You Find Out About Our Clinic?
Referred By A Friend Or Family.
Referred By Your Family Doctor.
Referred By Your Pharmacist.
Signs Posted Outside (On Building).
Internet.
Text Message From Our Clinic.
Mailer.
74
How Did You Find Us On The Internet?
Google Search.
Instagram.
Facebook.
Bing/Yahoo Search.
75
Reason For Referral By Family Doctor
Referred To See A Specialist At Our Clinic.
Referred To Speak To Walk-In Clinic Doctor.
Referred To Our In-house X-ray/Ultrasound Or Laborotary.
Should be Empty: