Intake Form for Family Physician
This form is for new patients who would like to join the clinic with a primary care provider. Please fill this form separately for each individual (including for minor) with accurate details.
I understand that the purpose of disclosing this personal health information to Belle Rive medical clinic (BMC) is for streamlining the intake process. I understand that I can refuse to consent and provide the information, and that I can retract my consent at any point.
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No
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Name
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First Name
Last Name
Sex
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Male
Female
Other
Date of Birth
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-
Month
-
Day
Year
Date
Country of Birth
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Please enter your Alberta Health Card number
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Phone Number (Cell)
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Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number (Home)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
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example@example.com
Preferred Language
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Complete Address
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Street Address
City
Province
Postal Code
Do you have any allergies?
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Who do you live with?
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Current/Previous Occupation(s)
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Marital Status
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Single
Married
Common Law
Other
How many children do you have?
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Please enter the name, relationship to patient and phone number of your emergency contact
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Did you or do you currently have a family physician?
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Please type your previous family physicians name if you had one and the reason for transfer. Eg. no family physician, family physician retired/retiring, family physician inaccessible or any other reason.
Past Medical History
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Please LIST any medical conditions you have been diagnosed with? (e.g. Type 2 diabetes, High blood pressure, Asthma, Depression, etc.)
Surgical History - (Have you ever had surgery?)
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Please SPECIFY the procedure, the YEAR it was completed, and the NAME of the surgeon.
Obstetrical History (Only if applicable)
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Please indicate the number of pregnancies and number of live births
Family History
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Are there any illnesses that run in your family? This includes parents, grandparents, siblings and children. Please LIST and SPECIFY which family members affected (e.g. Mother - High blood pressure, Father - Colon cancer)
Dosage of All Medications (Please include the MEDICATION NAME, DOSE, and FREQUENCY of administration)
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(e.g. Amlodipine 5mg - take 1 tablet once daily). This includes prescribed and over-the-counter medications, creams, herbs or supplements.
If you smoke, how many cigarettes per day and how many years have you smoked for?
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N/A if not applicable
If you are an ex-smoker, how many cigarettes per day on average, how many years did you smoke for, and what year did you stop?
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(e.g. Quit in 2010 and smoked 1 pack per day for 20 years). N/A if not applicable
If you drink alcohol, how often, and how many drinks per sitting?
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(e.g. 2 glasses of wine per week). N/A if not applicable
Do you use recreational drugs?
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(e.g. cannabis/marijuana, heroin, cocaine, ecstasy, etc.)? If yes, please indicate NAME of recreational drug, Quantity used, HOW OFTEN do you use it and how do you ADMINISTER them? (e.g. Cannabis 2 joints per week 0.5-1g per week). N/A if not applicable
Medication Allergies (Please include the MEDICATION NAME that you are allergic to and what REACTION happens if you take it?)
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(e.g. Penicillin – Rash, Throat swelling). N/A if not applicable
How many hours per week do you exercise?
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(e.g. running - 4 hours per week). N/A if not applicable
Depression screen
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Over the last 2 weeks, have you felt low in mood, hopeless or depressed?
Do you have private health insurance?
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(e.g. through work or private insurance company)
How did you hear about us
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(e.g. through family, friends, PCN find a doctor, Google, etc)
You are all done! Press submit to finish.
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