You can always press Enter⏎ to continue
Gynecology form
Hello, please fill out and submit this form before your appointment. To make it easy for you, we have pre-filled some questions based on the information we have in our system.
  • 1
    Format: Last name, First name
    Press
    Enter
  • 2
    Leave blank if you do not have a health card (i.e Out of country, refugee etc.)
    Press
    Enter
  • 3
    Enter phone number WITHOUT any dashes or '1" in front of it. For example: 9058979228. Enter the SAME PHONE NUMBER that you have been receiving text messages from the clinic.
    Press
    Enter
  • 4
    Enter in the following format: YYYY-MM-DD. For example: 2020-12-31 for December 31st, 2020
    Press
    Enter
  • 5
    Enter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6
    Press
    Enter
  • 6
    Press
    Enter
  • 7
    If none, leave blank
    Press
    Enter
  • 8
    Brief sentence (200 character limit).
    Press
    Enter
  • 9
    Press
    Enter
  • 10
    Press
    Enter
  • 11
    Press
    Enter
  • 12
    ex. July 1st 2018, 1 year ago, 2 months ago, etc.
    Press
    Enter
  • 13
    Press
    Enter
  • 14
    Press
    Enter
  • 15
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 16
    Press
    Enter
  • 17
    Press
    Enter
  • 18
    Leave blank if not applicable
    Press
    Enter
  • 19
    Press
    Enter
  • 20
    Press
    Enter
  • 21
    Press
    Enter
  • 22
    1 of 7
    Press
    Enter
  • 23
    If none, leave blank
    TextSizeCreated with Sketch.
    • Huge
    • Large
    • Normal
    • Small
    BoldCreated with Sketch.
    ItalicCreated with Sketch.
    UnderlineCreated with Sketch.
    Underline CopyCreated with Sketch.
    Ok
    NumberList Copy 2Created with Sketch.
    quoteCreated with Sketch.
    BreakCreated with Sketch.
    ImageCreated with Sketch.
    Ok
    SmileyCreated with Sketch.
    Press
    Enter
  • 24
    A bone mineral density exam (BMD) uses an x-ray machine to take pictures of bones to determine risk for osteoporosis, bone fractures or to monitor general bone health. Click here for more information
    Press
    Enter
  • 25
    How many months or years ago did you have this test done?
    Press
    Enter
  • 26
    Check any of the following that may apply
    Press
    Enter
  • 27
    Press
    Enter
  • 28
    Press
    Enter
  • 29
    Press
    Enter
  • 30
    Press
    Enter
  • 31
    Please provide all the medications you are taking if you can recall them
    Press
    Enter
  • 32
    List any known allergies you may have to medication below, if none, leave blank
    Press
    Enter
  • 33
    Press
    Enter
  • 34
    If you smoke, how often and how much do you smoke? If you do not smoke, leave this field blank.
    Press
    Enter
  • 35
    If you drink alcohol, please list how much you drink and how often. If you do not drink alcohol, leave this field blank.
    Press
    Enter
  • 36
    Are there any drugs you use? Provide info below.
    Press
    Enter
  • 37
    Press
    Enter
  • 38
    Please provide more details:
    Press
    Enter
  • 39
    Please provide more details:
    Press
    Enter
  • 40
    Please provide more details:
    Press
    Enter
  • 41
    Please provide more details:
    Press
    Enter
  • 42
    Please provide more details:
    Press
    Enter
  • 43
    Please provide more details:
    Press
    Enter
  • 44
    Please provide more details:
    Press
    Enter
  • 45
    Please provide more details:
    Press
    Enter
  • 46
    Please provide more details:
    Press
    Enter
  • 47
    Please provide more details:
    Press
    Enter
  • 48
    Press
    Enter
  • Should be Empty:
Question Label
1 of 48See AllGo Back
close
Save & Continue Later

Your form is saved successfully!

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Please enter a valid email address.

Something went wrong while saving your answers. Please try again.

Email has been sent successfully.

Save your progress

OR
Already have an account? LOGIN
Skip Create an Account

Save your progress

Terms of ServicePrivacy Policy

Your form submission has been saved as a draft.

If you want to continue answering your form later, please enter the email address you would like to send the link to:

Save your progress

OR
Forgot Password?

Your form submission has been saved as a draft.

We’ve sent you an email with a link to complete your submission.

Logout