New Client Form

Please complete this form prior to your first visit

Client Information

Last Name: ______First Name: ______Middle Name:______

PHIN #: ______MHSC #: ______

Birthdate: ______Gender: ______

Address: ______

Email address: ______

Home Phone Number: ______Work: ______Cell: ______

Preferred contact number: ______

Allergies: ______

Languages spoken/understood: ______

Preferred language of communication: English ☐ French ☐

Emergency Contact

Name:______Primary phone #:______Secondary phone #:______

Address: ______City: ______Postal Code: ______

Relationship to client: ______

Medical History

If your answer is “yes” to a question, please explain on the line following the question.

Thyroid Problems………………………………………………… / ☐Yes / ☐ No
Seizures…………………………………………………………….. / ☐Yes / ☐ No
Stroke……………………………………………………………...… / ☐Yes / ☐ No
Asthma……………………………………………………………. / ☐Yes / ☐ No
C.O.P.D(chronic obstructive pulmonary disease………………… / ☐Yes / ☐ No
Sleep Apnea ……………………………………………………… / ☐Yes / ☐ No
Heart Condition…………………………………………………... / ☐Yes / ☐ No
Congestive Heart Failure…………………………………………. / ☐Yes / ☐ No
Chest Pain………………………………………………………… / ☐Yes / ☐ No
High Blood Pressure……………………………………………… / ☐Yes / ☐ No
Elevated Cholesterol……………………………………………… / ☐Yes / ☐ No
Medical History (continued)……………………………………… / ☐Yes / ☐ No
Heart Attack………………………………………………………. / ☐Yes / ☐ No
Implantable Devices (ex: pacemaker)...………………………….. / ☐Yes / ☐ No
Irregular heart rate (ex: atrial fibrillation)………………………… / ☐Yes / ☐ No
Rheumatic Fever………………………………………………….. / ☐Yes / ☐ No
Diabetes…………………………………………………………... / ☐Yes / ☐ No
Liver Problems…………………………………………………… / ☐Yes / ☐ No
Stomach Problems………………………………………………... / ☐Yes / ☐ No
Irritable Bowel Syndrome………………………………………… / ☐Yes / ☐ No
Acid Reflux (ex: G.E.R.D)………………………………………. / ☐Yes / ☐ No
Kidney Problems/Bladder………………………………………… / ☐Yes / ☐ No
Incontinence of Urine…………………………………………….. / ☐Yes / ☐ No
Genitourinary Problems…………………………………………... / ☐Yes / ☐ No
Osteoporosis………………………………………………………. / ☐Yes / ☐ No
Back or neck problems…………………………………………… / ☐Yes / ☐ No
Arthritis…………………………………………………………… / ☐Yes / ☐ No
Skin Problems…………………………………………………….. / ☐Yes / ☐ No
Anemia……………………………………………………………. / ☐Yes / ☐ No
Blood Disorder……………………………………………………. / ☐Yes / ☐ No
Infectious Disease (ex:M.R.S.A/V.R.E, c-diff)…………………... / ☐Yes / ☐ No
Tuberculosis………………………………………………………... / ☐Yes / ☐ No
Hepatitis…………………………………………………………... / ☐Yes / ☐ No
HIV or AIDS……………………………………………………… / ☐Yes / ☐ No
STI (sexually transmitted infection)……………………………… / ☐Yes / ☐ No
Depression………………………………………………………... / ☐Yes / ☐ No
Anxiety……………………………………………………………. / ☐Yes / ☐ No
Eating Disorder…………………………………………………… / ☐Yes / ☐ No
Menstrual Problems………………………………………………. / ☐Yes / ☐ No
Abnormal Pap Test……………………………………………….. / ☐Yes / ☐ No
Cancer…………………………………………………………….. / ☐Yes / ☐ No
Other Medical Problems………………………………………….. / ☐Yes / ☐ No
Hospitalizations in the last 6 months……………………………... / ☐Yes / ☐ No
Are immunizations up to date…………………………………….. / ☐Yes / ☐ No
Previous reaction to immunizations………………………………. / ☐Yes / ☐ No
Are you sexually active…………………………………………… / ☐Yes / ☐ No
If yes, do you practice safe sex? / ☐Yes / ☐ No
Do you have any disabilities……………………………………… / ☐Yes / ☐ No

Surgical History

Have you had any surgeries? If so, please list them below with the year it was performed.

Medications

Please list all the medications you are taking, including any vitamins, herbal medicines, and “over the counter” medications

Name of medication / Dose / Frequency

Pharmacy used:______

Allergies

Do you have any allergies? Circle one YES NO

Please list any allergies below and the type of reaction:

Health Risk Profile

If your answer is “Yes” to a question, please explain on the line following the question.

Do you smoke? If yes, for how long and how many cigarettes per day?? ☐Yes ☐No ______

Are you a previous smoker? If yes, how many years…………………… ☐ Yes ☐No______

Did you smoke and how long ago did you quit? ______

Exposure to second hand smoke…………………….. ☐Yes ☐No ______

Other tobacco use……………………………………. ☐Yes ☐No ______

Alcohol use………………………………………….. ☐Yes ☐No If yes, frequency? ______

Recreational drug use……………………………….. ☐Yes ☐No If yes, frequency? ______

Caffeine Use…………………………………………. ☐Yes ☐No ______

Do you have stress factors?…………...... ☐Yes ☐No ______

Healthy Lifestyle

Do you exercise regularly?……………… ☐Yes ☐No if yes, frequency?______

Do you have dietary concerns?...... ☐Yes ☐No ______

Family History

Please describe any history of medical conditions (such as cancer, high blood pressure, diabetes etc.) in your immediate family (parents, siblings, grandparents)

______

Social History

Marital Status: ☐Married ☐Single ☐Divorced ☐Widowed ☐Other:______

Occupation: ______

Highest level of education completed: ☐College ☐ High School ☐ G.E.D. ☐ Other:______

Children: ☐ No ☐Yes-if yes, how many: ______, how old?

Housing (please circle) House Apartment Other:______

Household Members:

Surname / Given Names / Sex / Date of Birth (D/M/Y) / Relationship

Social support (please circle all that apply) EIA EI Old Age Security (OAS) Guaranteed Income Supplement (GIS)

Other service providers (please circle): None Home Care Family Services Psychiatrist Other Specialists:______

Are you a refugee? ☐Yes ☐No If yes, how long have you been in Canada? ______

Are you an immigrant to Canada? ☐Yes ☐No If yes, how long have you been in Canada? ______

Do you feel safe at home: ☐Yes ☐No

Do you want to discuss abuse: ☐Yes ☐No

Is someone threatening you: ☐Yes ☐No

Date:______Signature:______

Please bring all of your medications to your first appointment. Thank you.