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Patient Intake Form


For
Health Number
Care card/Health Card Issuing Province? (Required)

Personal Details


Yes No



Single Married Divorced Widowed

Male Female Others

Contact Details (Required)

Mailing Address (Required)

Medical Problems (Required)

None Diabetes Hypertension Elevated Cholesterol Asthma Heart Disease Stroke Cancer HIV/AIDS Depression Seizures Stomach Ulcers Glaucoma STD Psychiatric Disorder

Medication List (Optional)

Surgical History (Optional)

None Tonsillectomy Appendectomy Gallbladder Removal Hysterectomy Bowel Surgery Plastic Surgery

Allergies List (Required)

None Penicillin Amoxicillin Tetracycline Aspirin Ibuprofen Naproxen Sulpha Drugs Carbamazepine Lamotrigine Erythromycin Azithromycin Codeine Pseudoephedrine

Social History (Optional)


Yes No





Yes No

Yes No


Yes No



Yes No

Yes No



Yes No

Yes No

Travel History (Optional)


Yes No

Reason for Today’s Visit (Required)

COVID 19 Advice Prescription Refill General Health Question Cough/Cold/Flu/Fever Sore Throat Ear/Eye/Throat Urinary Infection Skin Problem (Acne/Rash/Eczema/Moles/Warts) Erectile Dysfunction (Viagra, Cialis, Levitra etc) Birth Control or Plan B Other

Please list symptoms which bothers you the most (Optional)

Pharmacy Preference

Emergency Contact (Optional)

Current Physician(s) and Specialists


The Physician has offered to communicate using the following means of electronic communication.
Phone Email Website / Portal Videoconferencing (including doxy, zoom and other secure video platform)
I acknowledge and understand that encryption software be used as a security mechanism for electronic communications, it is still possible that communications with the Physician or the Physician’s staff using the Services may not be encrypted. Despite this, I agree to communicate with the Physician or the Physician’s staff using these Services with a full understanding of the risk. I acknowledge that either I or the Physician may, at any time, withdraw the option of communicating electronically through the Services upon providing written notice.
Given to the increasingly complex nature of medicine and the reality that most people have more than one health care provider prescribing for them we must be able to access your current medication profile in order to protect you from potentially dangerous medication interactions and duplications. We believe that as a patient of 123 Walkin Clinic we have your implied consent to access PharmaNet. Please speak to your Primary Care Provider if you have any concerns.


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