New Patient Intake form:
Dixie Road Medical Associates
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2 /Unit no.
City
Province
Postal / Zip Code
Home Phone Number
*
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
*
Verify your Email
*
OHIP Healthcard Version Code
OHIP Healthcard Number
*
Date of Birth
*
 /
Day
 /
Month
Year
2 digit day, 2 digit month, 4 digit year
1
Gender
*
Please Select
Male
Female
Have you been told you have any of the following :
*
Rows
YES
NO
Comments
Ischemic heart disease/ Previous Heart attack
2
3
Atrial Fibrillation
4
5
Diabetes
6
7
Hypertension
8
9
COPD
10
11
Asthma
12
13
CVA/ Stroke / TIA or mini-stroke
14
15
Thyroid Problems
16
17
Arthritis
18
19
Depression
20
21
Anxiety
22
23
Other Mental Health condition
24
25
Are you a smoker?
26
27
Any drug misuse?
28
29
Alcohol Misuse?
30
31
Any other medical problems? Please describe :
*
Any previous surgeries :
*
Current Medications and dosages
*
Significant Family History
*
Allergies
*
Social Background
*
Contact in case of emergency / Next of Kin
*
First Name
Last Name
Emergency Contact Phone Number
*
Format: (000) 000-0000.
Relationship
*
Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us?
*
Please Select
Newspaper
Google
Facebook
Street sign
friends or family
Other (Please specify...)
Submit
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