LifeCure – Ear, Sinus & Sore Throat Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Sex at Birth* This field is required.
Female
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Intersex
Prefer not to say
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Morocco
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Nagorno-Karabakh
Namibia
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Nepal
Netherlands
Netherlands Antilles
New Caledonia
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Niger
Nigeria
Niue
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Poland
Portugal
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Qatar
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Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Isle of Man
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Yemen
Zambia
Zimbabwe
Other
Country
5
OHIP / Health Card Number
6
Date of Visit
Date
Month
Day
Year
7
Email Address* This field is required.
example@example.com
8
Phone Number* This field is required.
Please enter a valid phone number.
9
Pharmacy Name
10
Pharmacy Address
11
Pharmacy Phone
12
Pharmacy Fax
13
Medication Coverage* This field is required.
ODB (Government)
Trillium Drug Plan
None
Private Insurance
14
Insurance Provider Name* This field is required.
15
Carrier ID* This field is required.
16
Client ID* This field is required.
17
Group Number
18
Upload Insurance Card (optional)
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19
What is the reason for today’s visit?* This field is required.
Ear pain / suspected ear infection
Sinus pain or pressure
Sore throat
Combination of the above
Other
20
When did your symptoms start?* This field is required.
Today
1–2 days
3–5 days
More than 5 days
21
Overall, are your symptoms:* This field is required.
Improving
Worse
Same
22
Recent swimming or water exposure?* This field is required.
Yes
No
23
How severe are your symptoms?* This field is required.
Mild
Moderate
Severe
24
Are you able to eat or drink?* This field is required.
Yes
Some difficulty
No
25
Ear Symptoms (select all that apply)
Ear pain (Left)
Ear pain (Right)
Ear pain (Both)
Ear pressure/fullness
Decreased hearing
Ear discharge
Pain when pulling ear
Fever
26
Sinus Symptoms (select all that apply)
Facial pain/pressure
Worse bending forward
Nasal congestion
Thick nasal discharge
Headache
Tooth pain
Reduced smell
27
Sore Throat Symptoms (select all that apply)
Throat pain
Pain when swallowing
Swollen neck glands
Fever
White patches on tonsils
No cough
28
Severe or rapidly worsening pain?* This field is required.
Yes
No
29
Facial or eye swelling?* This field is required.
Yes
No
30
Difficulty breathing or swallowing?* This field is required.
Yes
No
31
Drooling / unable to swallow saliva?* This field is required.
Yes
No
32
Difficulty opening mouth (trismus)?* This field is required.
Yes
No
33
One-sided throat swelling?* This field is required.
Yes
No
34
High fever (>39°C)?* This field is required.
Yes
No
35
Confusion or extreme drowsiness?* This field is required.
Yes
No
36
Ear discharge with severe pain or hearing loss?* This field is required.
Yes
No
37
Close contact with strep?* This field is required.
Yes
No
38
Symptoms for more than 10 days without improvement?* This field is required.
Yes
No
39
Symptoms improved then worsened again?* This field is required.
Yes
No
40
Current medications (please list all)
41
Do you have any medication allergies?* This field is required.
No
Yes
42
List medication allergy* This field is required.
43
Type of reaction* This field is required.
44
Have you taken antibiotics in the last 3 months?* This field is required.
Yes
No
45
Has anything helped your symptoms?* This field is required.
Yes
Somewhat
No
46
Medical History (select all that apply)
High blood pressure
High cholesterol
Heart disease
Asthma / COPD
Diabetes
Liver disease
Kidney disease
Immune condition / medications
Cancer
Obesity
Pregnancy / postpartum
Chronic sinus / ear infections / strep
None
Other
47
Are you currently pregnant or possibly pregnant?
Yes
No
48
Are you currently breastfeeding?
Yes
No
49
Immune Suppression Conditions (select all that apply)
HIV
Cancer
Organ transplant
Lupus
Splenectomy
None
50
Immune Suppression Medications (select all that apply)
Steroids
Chemotherapy
Biologics
None
51
Is there anything else we should know?
52
Upload bloodwork if available (optional)
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53
I confirm the information I provided is accurate.* This field is required.
54
I consent to being contacted by Lifecure.* This field is required.
55
Preferred contact method* This field is required.
Phone
Email
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