Noongwa Wellness New Patient Intake Form

Please complete this form to register for services at the Noongwa Wellness. We ask each patient to complete the New Patient Intake Form. We recognize there is a lot of information requested, but required fields are clearly marked with an asterisk (*). Please complete as much of the form as possible, as this will help us streamline your first visit and ensure you receive the best care.

If you require assistance with completing the form, please contact us at admin@noongwa.ca.

Thank you for choosing the Noongwa Wellness to support your care!

I am completing this form for:*

MyselfMy ChildOther

If you are completing the form on behalf another person, please share who you are completing this form for.

Name of Patient (Child or Other above)

Legal Name (as written on your identification)*

First Name of PatientLast Name of Patient

Preferred Name (optional)

Your preferred pronouns help us address you respectfully. You may write them below or leave blank if you prefer. For example, She/Her, He/Him, They/Them, or a Self Described Pronoun. (optional)

Do you identify as a member of the 2SLGBTQ+ community? (optional)

YesNoOther

If other, please share how you identify yourself

Do you identify as*

If other, please share how you identify yourself

Do you live on the reserve?*

YesNo

Address*

Street Address

Street Address Line 2

CityProvince

Postal Code

Preferred Contact Phone Number (if you do not have a phone number please enter 000-000-0000)*

Please enter a valid phone number.

Do we have your permission to leave a voicemail*

with Spouse/Partnerwith any Family Memberon your voicemailI do not give permission for a voicemail to be left

The best time to reach me by phone is:

MorningsLunch hour (12pm-1pm)Afternoon

Email*

example@example.com

Birthdate*

Date

Sex assigned at birth (This is important for Preventative Care and will only be used for medical purposes)*

Woman/FemaleMan/MalePrefer not to say

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Please enter a valid phone number.

Emergency Contact Email

example@example.com

Relationship to Emergency Contact*

To help us provide you with healthcare services, please provide your Ontario Health card information. Refer to the image below for where to find the Health Card Number and Version Code.

Health Card Number (10 digits, for example: 2345 678 912)*

Version Code (2 digits, for example: AB)*

Health Code Expiry Date*

Are you affiliated with a First Nation community? If not, please write N/A)*

Certificate of Indian Status Card Number (optional)

Band Number (optional)

Have you previously had a Family Physician or Primary Care Provider?*

YesNo

If yes, what is their name and when was your last appointment with the Primary Care Provider or their staff?

Month, Year

What is your preferred Pharmacy? (optional)

Pharmacy Name

Street Address

CityProvince

Postal

Pharmacy Phone Number

Please enter a valid phone number.

Pharmacy Fax Number

Please enter a valid phone number.

This section is asking about any allergies that you may have. If you do not have any allergies, please leave these questions blank.

I am allergic to the following FOODS (optional)

My food allergies cause (choose all that apply)

Anaphylaxis/Respiratory swelling and difficulty BreathingSkin reaction (for example, itchy, rash, or hives)Other

If you have multiple food allergies with different reactions please list them below. For example, 1) Peanuts - anaphylaxis 2) Strawberries - hives/rash

I am allergic to the following MEDICATIONS (optional)

My medication allergies cause:

Anaphylaxis/Respiratory swelling and difficulty BreathingSkin reaction (for example, itchy, rash, or hives)Other

If you have multiple medication allergies with different reactions please list them below.

I have ENVIROMENTAL/SEASONAL allergies. Please list the allergies. (optional)

My medication allergies cause:

Anaphylaxis/Respiratory swelling and difficulty BreathingSkin reaction (for example, itchy, rash, or hives)Other

If you have multiple environmental/seasonal allergies with different reactions please list them below.

Please list all medications you are currently taking, including the dose and how often each medication is taken.

This information is important to ensure safe and effective care, avoid potential drug interactions, and help your new healthcare provider make informed decisions.

Are you currently taking any PRESCRIPTION medications?*

YesNo

If yes, list your medications including the medication name, dose and frequency you take the medication. For example, Metformin, 500mg, twice per day.

Are you currently taking any OVER-THE-COUNTER medications? (Medications without a prescription such as Advil, Gravol, or Benadryl)*

YesNo

If yes, list your over the counter medications including the dose and frequency you take the medication.

Are you currently taking any VITAMINS? (For example Vitamin D, C, or Calcium)*

YesNo

If yes, list your vitamins including the dose and frequency you take the medication.

Are you currently taking any naturopathic medications or herbal medications in any form? Please include pill form, liquids, sprays, inhalations and creams.

For example:

Minerals such as Zinc, Iron, Potassium etc.

Nutritional supplements such as fish oil, probiotics etc.

Herbals such as St Johns Wart, Echinacea, Ginseng, Turmeric etc.

Essential oils such as eucalyptus, camphor etc.

I am currently taking NATUROPATHIC medications*

YesNo

If yes, list your naturopathic medications including the dose and frequency you take the medication.

Do you have drug benefit coverage?*

NIHB (Non-Insured Health Benefits)Ontario Drug Benefit (ODB)Private InsuranceNo coverage

Narcotics Statement

In alignment with Noogngwa Health's mission to support our patients in improving their overall health and achieving a balanced state of well-being, narcotics may be prescribed in accordance with regulatory authorization under specific circumstances—for example, in cases of cancer, palliative care, or acute injury.

Noogngwa Health will work closely with you as our patient and your family, using an integrated care approach to explore and consider alternative treatment options. These may include internal referrals to Traditional Healing, Massage Therapy, Physiotherapy, or Mental Health services.

When appropriate, external referrals may also be arranged to help address pain management needs. These referrals will be discussed with the client and agreed upon as appropriate, based on the clinical judgement of the medical professionals at Noogngwa Health.

I have read the Narcotics Statement*

This section is asking about your personal medical history.

For each listed condition please choose the most appropraite staus.

Anxiety*