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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
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  • 2
    Leave blank if you do not have a health card (i.e Out of country, refugee etc.)
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  • 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.
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  • 4
    Enter in the following format: YYYY-MM-DD. For example: 2020-12-31 for December 31st, 2020
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  • 5
    Enter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6
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  • 7
    If none, leave blank
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  • 8
    Brief sentence (200 character limit).
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  • 12
    ex. July 1st 2018, 1 year ago, 2 months ago, etc.
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    Leave blank if not applicable
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    1 of 7
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    If none, leave blank
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  • 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
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  • 25
    How many months or years ago did you have this test done?
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  • 26
    Check any of the following that may apply
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  • 27
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  • 31
    Please provide all the medications you are taking if you can recall them
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  • 32
    List any known allergies you may have to medication below, if none, leave blank
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  • 33
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  • 34
    If you smoke, how often and how much do you smoke? If you do not smoke, leave this field blank.
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  • 35
    If you drink alcohol, please list how much you drink and how often. If you do not drink alcohol, leave this field blank.
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  • 36
    Are there any drugs you use? Provide info below.
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  • 37
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  • 38
    Please provide more details:
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  • 39
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  • 40
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  • 41
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  • 42
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  • 43
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  • 44
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  • 45
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  • 46
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  • 47
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  • 48
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