Appointment Form
Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name
*
First Name
Last Name
Date of Birth
*
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Day
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Year
Gender
*
Please Select
Male
Female
Not willing to Disclose
Do you have a valid Ontario Health Card?
*
Yes
No
Health Card Number
*
Version Code
*
Phone Number
*
Format: (000) 000-0000.
Email
*
example@gmail.com
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
ADHD
Please answer the questions below, rating yourself on each of the criteria . As you answer each question, select the single choice that best describes how you have felt and conducted yourself over the past 6 months. This form can be be submitted and will be discussed with your health care professional in you visit
Rows
Never
Rarely
Sometimes
Often
Very Often
1. How often do you have trouble wrapping up the final details of a project, once thechallenging parts have been done?
2. How often do you have difficulty getting things in order when you have to do a task thatrequires organization?
3. How often do you have problems remembering appointments or obligations?
4. When you have a task that requires a lot of thought, how often do you avoid or delay gettingstarted?
5. How often do you fidget or squirm with your hands or feet when you have to sit down for along time?
6. How often do you feel overly active and compelled to do things, like you were driven by amotor?
7. How often do you make careless mistakes when you have to work on a boring or difficultproject?
8. How often do you have difficulty keeping your attention when you are doing boring orrepetitive work?
9. How often do you have difficulty concentrating on what people say to you, even when theyare speaking to you directly?
10. How often do you misplace or have difficulty finding things at home or at work?
11. How often are you distracted by activity or noise around you?
12. How often do you leave your seat in meetings or in other situations in which you areexpected to stay seated?
13. How often do you feel restless or fidgety?
14. How often do you have difficulty unwinding and relaxing when you have time to yourself?
15. How often do you find yourself talking too much when you are in social situations?
16. When you’re in a conversation, how often do you find yourself finishing the sentences of thepeople you are talking to, before they can finish it themselves?
17. How often do you have difficulty waiting your turn in situations when turn taking is required?
18. How often do you interrupt others when they are busy?
Medical History
Do you have any food or drug allergies?
Yes
No
Please provide the list of your allergies below
*
Do you use any medications?
*
Yes
No
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.
*
Female Patients Only
Date of your last period
-
Month
-
Day
Year
Date
Current contraceptive/Birth control use:
Oral contraception
IUD (Mirena, copper IUD)
Tubal ligation (tubes tied)
Hysterectomy and/or ovaries removed
None
Is there a specific medication you would like to request?
*
Yes
No
What is your requested medication name and dose?
*
Do you agree to receive text reminders for your appointment?
*
Yes
No
Submit
Should be Empty: