Enrolment Waitlist for Family Physician
This form is for new patients who would like to join the waitlist for enrolment with a Family Physician. Please fill out this form separately for each individual (including minors) with accurate details.
I understand that the purpose of disclosing this personal health information to GFHC is for streamlining the intake process. I understand that I can refuse to consent and provide the information, and that I can retract my consent at any point.
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Yes
No
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Name
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First Name
Last Name
Sex
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Male
Female
Non-Binary
Other
Date of Birth
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-
Year
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Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Country of Birth
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Phone Number (Cell)
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Format: (000) 000-0000.
Phone Number (Home)
Format: (000) 000-0000.
Email
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example@example.com
Preferred Language
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Complete Address
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Street Address
Street Address Line 2
City
Province
Postal Code
Current/Previous Occupation(s)
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If retired, what was your previous occupation(s)?
Marital Status
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Single
Married
Common Law
Other
How many children do you have?
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Who do you live with?
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Did you or do you currently have a family physician?
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Please type your previous family physicians name if you had one and the reason for transfer. Eg. no family physician, family physician retired/retiring, family physician inaccessible or any other reason.
Family History
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Are there any illnesses that run in your family? This includes parents,grandparents, siblings and children. Please LIST and SPECIFY which familymembers affected (e.g. Mother - High blood pressure, Father - Colon cancer)
Past Medical History
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Please LIST any medical conditions you have been diagnosed with? (e.g. Type 2 diabetes, High blood pressure, Asthma, Depression, etc.)
Surgical History - (Have you ever had surgery?)
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Please SPECIFY the procedure, the YEAR it was completed, and the NAME of the surgeon.
Obstetrical History (Only if applicable)
Please indicate the number of pregnancies and number of live births.
Dosage of All Medications (Please include the MEDICATION NAME, DOSE, and FREQUENCY of administration)
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(e.g. Amlodipine 5mg - take 1 tablet once daily). This includes prescribed and over-the-counter medications, creams, herbs or supplements.
If you smoke, how many cigarettes per day and how many years have you smoked for?
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N/A if not applicable
If you are an ex-smoker, how many cigarettes per day on average, how many years did you smoke for, and what year did you stop?
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(e.g. Quit in 2010 and smoked 1 pack per day for 20 years). N/A if not applicable
If you drink alcohol, how often, and how many drinks per sitting?
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(e.g. 2 glasses of wine per week). N/A if not applicable
Do you use recreational drugs?
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(e.g. cannabis/marijuana, heroin, cocaine, ecstasy, etc.)? If yes, please indicate NAME of recreational drug, Quantity used, HOW OFTEN do you use it and how do you ADMINISTER them? (e.g. Cannabis 2 joints per week 0.5-1g per week). N/A if not applicable
Medication Allergies (Please include the MEDICATION NAME that you are allergic to and what REACTION happens if you take it?)
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(e.g. Penicillin – Rash, Throat swelling). N/A if not applicable
How many hours per week do you exercise?
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(e.g. running - 4 hours per week). N/A if not applicable
Depression screen
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Over the last 2 weeks, have you felt low in mood, hopeless or depressed?
Do you have private health insurance?
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(e.g. through work or private insurance company)
Preferred pharmacy
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Please type the NAME and ADDRESS of the pharmacy you would be using and would like to have on your chart.
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