Respirology

1

Patient Full Name* This field is required.Format: Last name, First name

2

Health Card NumberLeave blank if you do not have a health card (i.e Out of country, refugee etc.)

3

Cellphone Number* This field is required.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.

4

Date Of Birth* This field is required.Enter in the following format: YYYY-MM-DD. For example: 2020-12-31 for December 31st, 2020

5

Current Address Including postal codeEnter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6

6

Email

example@example.com

7

Were you born and raised in Canada. If not which country were you born in and when did you move to Canada?* This field is required.

8

Do you smoke? If yes how frequently and how much do you smoke? (Leave blank if not applicable) Example: Smoke 3 times a day, 2 cigarettes each time

9

Have you ever smoked? If so when did you quit smoking? (Leave blank if not applicable)

10

Please list all previous and current occupation(s) (Leave blank if not applicable)

11

Do you have environmental allergies (dust, pollen, etc), if yes please list them below

12

Have you ever been diagnosed with tuberculosis(TB), if so were you treated, when were you treated and how long was your treatment?Example: Diagnosed 3 years ago, was treated for 6 months in 2018

13

Did you ever get a BCG/TB vaccine?

Yes

No

I don't know

14

Have you ever been diagnosed with asthma or COPD?

YESNO

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