Lifecure – GERD / Heartburn Intake Form

1
Full Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
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Day
Year
3
Sex at Birth* This field is required.
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4
Address
Street Address
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Saint Barthelemy
Saint Helena
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Samoa
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Senegal
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eSwatini
Sweden
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Taiwan
Tajikistan
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Thailand
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Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
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Vatican City
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Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
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
Preferred Pharmacy Name
10
Preferred Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Preferred Pharmacy Phone
Please enter a valid phone number.
12
Preferred Pharmacy Fax
13
Medication Coverage
ODB (Government)
Trillium Drug Plan
None
Private Insurance
14
Private Insurance Provider Name* This field is required.
15
Carrier ID* This field is required.
16
Client ID* This field is required.
17
Group Number* This field is required.
18
Upload Insurance Card (optional)
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19
Reason for Visit – What brings you in today?
Burning sensation in chest or throat
Sour or bitter taste in mouth
Regurgitation of food or liquid
Upper abdominal discomfort
Chronic cough or throat clearing
Hoarseness / voice changes
Difficulty swallowing
Medication refill / follow-up
Other
20
When did symptoms start?
Today
1–2 days
3–7 days
More than 1 week
More than 3 months
21
Current trend
Improving
Worse
Same
22
Symptom frequency
Less than once per week
1–2 times per week
3–5 times per week
Daily
23
When are symptoms most noticeable?
After meals
Lying down or bending
Daytime
Nighttime
No clear pattern
24
Symptoms (Select all that apply)
Burning behind the breastbone
Acid taste / reflux into mouth
Chest pressure / discomfort / pain
Nausea
Bloating
Belching
25
Associated & Red Flag Symptoms (Select all that apply)
Chronic cough
Throat clearing
Hoarseness
Shortness of breath
Persistent vomiting
Unintentional weight loss
Black / tarry stools
Blood in vomit
Pain radiating to arm / jaw / back
Difficulty or painful swallowing
New symptoms after age 50
26
Have symptoms worsened with any of the following?
Spicy / fatty foods
Chocolate / mint
Coffee / caffeine
Alcohol
Large meals
Late-night eating
Stress
No clear trigger
27
Medical History (Select all that apply)
Heart disease
High blood pressure
Diabetes
Asthma
Hiatal hernia
Previous stomach ulcers
Barrett’s esophagus
None
28
Regular use of any of the following? (Select all that apply)
NSAIDs
Aspirin
Steroids
Alcohol
Tobacco
29
Treatments tried (Select all used)
Antacids (Tums / Gaviscon)
H2 blockers (famotidine)
PPIs (pantoprazole / omeprazole)
Dietary changes
30
Did it help?
Yes
Somewhat
No
31
Current medications (please list all)
32
Are you currently taking blood thinners?
Yes
No
33
Do you have any medication allergies?
No
Yes
34
Please list medication allergies and describe your reaction* This field is required.
35
Have you started any new medications recently?
Yes
No
36
Pregnant or possibly pregnant?
Yes
No
37
Are you currently breastfeeding?
Yes
No
38
Immune suppression conditions (select all that apply)
HIV
Cancer
Organ transplant
Lupus
Splenectomy
None
39
Immune suppression medications (select all that apply)
Steroids
Chemotherapy
Biologics
None
40
Is there anything else we should know?
41
Upload bloodwork if available (optional)
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42
I confirm the information I provided is accurate.* This field is required.
43
I consent to being contacted by Lifecure.* This field is required.
44
Preferred contact method* This field is required.
Phone
Email
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