Patient Form

Medical History Form for Intake Appointments

Only individuals with a scheduled intake appointment should complete this form. Please submit it at least 2 business days in advance.

Intake Appointment Date *

Only individuals with confirmed intake appointments should complete this form.

Legal Name *

(As it is listed on your health card)

Preferred Name

OHIP Number *

10 digits, no letters or spaces.

OHIP Version Code *

The two letters on your card.

Date of Birth *

Address *

Personal & Demographic Information

Pronouns

Sex Assigned at Birth *

Gender Identity (if comfortable disclosing)

Sexual Orientation (if comfortable disclosing)

Country of Birth *

First Language *

Ethnicity

Feel free to use any terms that you feel represent you.

Lifestyle & Social History

Occupation *

Relationship Status *

Children *

Smoking History *

Alcohol History *

Other Recreational Substances *

Medical History

Current / Ongoing Medical Conditions *

Previous / Resolved Medical Conditions, Surgeries, Hospitalizations *

Prescription Medications *

Please include name, dose/strength, and frequency.

Over-the-Counter and Herbal Products *

Allergies *

Please include the trigger and the reaction.

Family Medical History *

Please list conditions in immediate family members and age of diagnosis, if known.

Healthcare Information & Accessibility

Previous Family Doctor Contact Information *

Specialists Involved In Your Care *

Preferred Pharmacy *

Beaches clinic co-located pharmacy (IDA Queen East)

Midtown clinic co-located pharmacy (Viva Pharmacy)

I prefer to use a different pharmacy

Other Pharmacy Contact Information

Disabilities and Accessibility Needs

Income Support or Affordability Concerns (if comfortable disclosing)

Consent & Acknowledgement

I understand this form will NOT be reviewed by a medical professional prior to my scheduled appointment. *

I understand I will not be a patient of the assigned physician until after my intake appointment has been completed. *