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 / ☐ NoSeizures…………………………………………………………….. / ☐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 / FrequencyPharmacy 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) / RelationshipSocial 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.