Smiths Falls
Nurse Practitioner-Led Clinic
Cliniques dirigées par du personnel
infirmier praticien Smiths Falls
CLIENT PERSONAL INFORMATION
______________
First Name
_____
Initial
___________________
Last Name
Date of Birth: MM_____DD____YYYY____
__________________
Preferred Name
Gender:
□Male □Female
Health Card Number:_______________ Version Code____ Expiry Date:________
MM/DD/YYYY
What is your preferred pharmacy?______________________________________
CLIENT CONTACT INFORMATION
Actual/Mailing Address:______________________________________________
___________________
___________________
____________________
City
Province
Postal Code
___________________
___________________
____________________
Home Telephone
Work Telephone
Cell Phone
□ When necessary, I give consent for Smiths Falls N.P.L.C. to leave a message
on my phone asking me to return a phone call.
Email Address: ______________________________________________________
Optional
Country of Birth:
□ Canada
Other:_____________ Year of Arrival ________
Smiths Falls
Nurse Practitioner-Led Clinic
Cliniques dirigées par du personnel
infirmier praticien Smiths Falls
EMERGENCY CONTACT INFORMATION
________________________________
Emergency Contact Name
__________________
Home Telephone
___________________________
Relationship
__________________
Work Telephone
__________________
Cell Phone
Who was your previous Physician/Nurse Practitioner?______________________
Address/Phone#:____________________________________________________
Are you seeing a Specialist?
Name
□Yes or □NO. If yes please provide:
Specialty
Address
Phone
If Applicable:
Power of Attorney for Personal Care:____________________________________
Relationship to you: _________________________________________________
Contact Information: _________________________________________________
Please bring prescription medications and Herbal, vitamins, etc., with you
to your “Meet & Greet” appointment.
SMITHS FALLS NURSE PRACTITIONER-LED CLINIC
CLIENT INTAKE FORM
NAME:
___________________________
D.O.B:
______________
Age:_______
The following questions are asked to collect information pertaining to the determinants of health:
Ethnicity:
Metis □
Caucasian □
South Asian □
Asian □
Other □
First Nation □
Education: (Check highest level of achievement):
Grade School □
High School □
College □
Employment Status:
Full time □
Retired □
Part time □
Unemployed □
Self Employed □
African-Canadian □
University □
Temporary □
Seeking employment □
Employed □
Homemaker □
Occupation:
Marital Status: Single □
Married □ Common Law □ Separated □
Divorced □ Widowed □
Name of Partner: _________________________________________________________________
Names and Ages of Children:
Name
Birthdate
Age
Lives with you
CLIENT LIFESTYLE HISTORY
Exercise/Activity:
Type
How many minutes/day
How often
Do you smoke or use tobacco (cigarettes, cigars, chewing tobacco, or pipe smoking)?
YES □
NO □
How old were you when you started? ______
How many years have you been smoking? ______
How many per day?_____
Are you interesting in quitting? ______
Do you drink alcohol? YES □ NO □
If yes, do you drink Beer□ Liquor□ Wine□
How many drinks per week? ______________
Do you currently use recreational drugs? YES □
NO □
If yes, please specify type _____________________________________________________
Method of administration _____________________________________________________
Have you considered stopping? _________________________________________________
Do you currently drink caffeinated beverages such as coffee, tea, pop or energy drinks?
YES □
NO □
If yes, how many per day____________________________
Do you drive a motor vehicle? ___________
Do you wear your seatbelt? Yes □
NO□
How would you rate your stress level from 1 to 10? ___________________________________
(1 being the lowest to 10 being the highest)
HEALTH HISTORY
Allergies: YES □ NO □
Medications
If yes see below:
Type of Reaction
Food/Environmental
Type of Reaction
What are your 3 major health Concerns?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Do you carry an Epipen? Yes □ No □
Do you wear a medical alert? Yes □ No □
Have you ever had allergy testing? Yes □ No□
Vaccination History:
□ OPV (Polio) mm____ yyyy____________
□ MMR (Measles, mumps, rubella) mm_____ yyyy______
□ Hep A mm______ yyyy_______
□ Influenza mm_______ yyyy_________
□ Hep B mm______ yyyy_______
□ Pneumovax mm______ yyyy________
□ TB Test mm______ yyyy______ Result ____
□ Gardasil mm________ yyyy_________
□ Zostavax (Shingles vaccine) mm______ yyyy______
□ DPT/TD (Tetanus) mm_____ yyyy_______
Childhood Illness:
□Asthma
□Chickenpox
□Ear Infections
□Measles
□Mumps
□Rubella
Other (Description) ____________________________________________________________________
Medical History:
□ Asthma
□ Anemia
□ Anxiety
□ Bronchitis
□ Cancer
□ Chest Pain
□ Constipation
□ Depression
□ Diabetes
□ Headaches
□ Heartburn
□ Heart disease/Angina
□ High Cholesterol
□ High Blood Pressure □ HIV/AIDS
□ Kidney Problems □ Myocardial Infarction
□ Osteoporosis
□ Sinus Problems
□ Stress Incontinence
□ Stroke
□ Other ______________________________________________________
□ Arthritis
□ Back Pain
□ Chronic Pain
□ Diarrhea
□ Hepatitis
□ Migraines
□ Seizures
□ Weight Loss
Number of:
Pregnancies
______ Live Births ______ Miscarriages _______ Abortions _______
Surgical History
□ Appendectomy (year___________)
□ Breast Surgery (year___________)
□ Bypass Surgery (year ___________)
□ Carpal Tunnel Release (year __________)
□ Cataract Surgery (year__________)
□ Removal of Gallbladder (year_______)
□ Other (Description)
□ Hernia Repair (year____________)
□ Hip Replacement (year_________)
□ Hysterectomy (year ____________)
□ Knee Replacement (year________)
□ Prostate Surgery (year _________)
□ Tonsillectomy (Year _________)
_______________________________________________________________
_______________________________________________________________
Medications/Supplements:
Need
Refill
Need
Refill
Preventative Screening History:
Date of Last: Colon cancer screening test ___________ Colonoscopy_____________
Pap smear_____________
Mammogram_____________
Bone Mineral Density____________
PSA Blood Test ____________
Routine Blood Work _____________
Family History:
Living
Age(Or Age At Death)
Cause of Death
Daughter
□Yes
□Yes
□Yes
□No
□No
□No
___________________
___________________
___________________
____________________
____________________
____________________
Son
□Yes
□Yes
□Yes
□No
□No
□No
___________________
___________________
___________________
____________________
____________________
____________________
Mother
□Yes
□No
___________________
____________________
Maternal Grandmother
Maternal Grandfather
□Yes
□Yes
□No
□No
___________________
___________________
____________________
____________________
Father
□Yes
□No
___________________
____________________
Paternal Grandmother
Paternal Grandfather
□Yes
□Yes
□No
□No
___________________
___________________
____________________
____________________
Sister
□Yes
□Yes
□Yes
□No
□No
□No
___________________
___________________
___________________
____________________
____________________
____________________
Brother
□Yes
□Yes
□Yes
□No
□No
□No
___________________
___________________
___________________
____________________
____________________
____________________