Patient Medical History Form

Patient Enrollment Form

office@dynamicmedicalclinic.ca
Patient Name*

First NameLast Name
Alberta Health Care Number*
Email
example@example.com
Patient Birth Date*

MonthDayYear
Patient Gender*
Age
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number
Please enter a valid phone number.
Patient Pharmacy
Please list your current pharmacy
Next of Kin Name/Relationship
Common Law, Parent etc.
Next of Kin Phone Number
Please enter a valid phone number.
Patient Height (cm's)*
Patient Weight (kg's)*
Reason for seeing the doctor:*
Patient Medical History
Please list any drug allergies
MEDICAL HISTORY: Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerDiabetesEmotional DisorderEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Patient Enrollment Form

office@dynamicmedicalclinic.ca
Patient Name*

First NameLast Name
Age
Patient Gender*
Patient Birth Date*

MonthDayYear
Alberta Health Care Number*
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.
Patient Height (cm's)*
Patient Weight (kg's)*
Reason for seeing the doctor:*
Patient Medical History
Please list any drug allergies
MEDICAL HISTORY: Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerDiabetesEmotional DisorderEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Patient Enrollment Form

office@dynamicmedicalclinic.ca
Patient Name*

First NameLast Name
Age
Patient Gender*
Patient Birth Date*

MonthDayYear
Alberta Health Care Number*
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.
Patient Height (cm's)*
Patient Weight (kg's)*
Reason for seeing the doctor:*
Patient Medical History
Please list any drug allergies
MEDICAL HISTORY: Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerDiabetesEmotional DisorderEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Patient Enrollment Form

office@dynamicmedicalclinic.ca
Patient Name*

First NameLast Name
Age
Patient Gender*
Patient Birth Date*

MonthDayYear
Alberta Health Care Number*
Patient E-Mail*
example@example.com
Phone Number
Please enter a valid phone number.
Patient Height (cm's)*
Patient Weight (kg's)*
Reason for seeing the doctor:*
Patient Medical History
Please list any drug allergies
MEDICAL HISTORY: Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerDiabetesEmotional DisorderEpilepsy SeizuresGallstonesHeart DiseaseHeart AttackHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations and Dates of Each
Please list your Current Medications
Exercise

Never1-2 days3-4 days5+ days
Alcohol Consumption

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Should be Empty:

Patient Enrollment Form

Patient Medical History

Patient Enrollment Form

Patient Medical History

Patient Enrollment Form

Patient Medical History

Patient Enrollment Form

Patient Medical History