Nephrology

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
Please provide a list of all past medical history or surgeries (leave blank if not applicable)Example: Breast surgery 3 years ago, Diabetes 4 years etc
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8
If you're currently on medication please provide the dose/how long you've been on the medication (leave blank if not applicable)Example: Sertraline 50mg daily
9
Do you have any allergens? If so please list them below (leave blank if not applicable)Allergen is what you're allergic to (Example: Pollen)
10
Do you have any family history of kidney disease, if so please list all past history (leave blank if not applicable)Example: Mom Kidney Disease
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11
Do you smoke? If so, how frequently and how much? (leave blank if not applicable)
12
Do you drink alcohol? If so how frequently and how much? (leave blank if not applicable)
13
Do you OR have you used and Intravenous drugs. If so please list all past history (leave blank if not applicable)Example of Intravenous drugs: Heroin, cocaine, prescription opioids, and methamphetamine
14
Do you have any history of using NSAID's (Nonsteroidal anti-inflammatory drugs) If so please list all past history below. (leave blank if not applicable)Examples of NSAID's: Aspirin, Ibuprofen, Naproxen, Ketoprofen, Daypro, Indocin, Iodine, Naprosyn, Relafen, Vimovo, Voltaern)
15
Have you ever had to use contrast materials for a medical test. (Typically used for x-rays, CT/MR scans and ultrasounds). (leave blank if not applicable)
16
Any history of shortness of breath?
YESNO
17
Any history of bleeding or sore throat?
YESNO
18
Any history of lower limb swelling?
YESNO
19
Do you have any history of previous abnormal Kidney function, blood work, urine tests, or ultrasound kidney tests? If so please list below all past history. (leave blank if not applicable)
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