New patient information New Patient Intake Form Download PDF PERSONAL INFORMATION Last Name First Name Date of Birth (DD/MM/YYYY) Email Address Phone Number Sex Male Female Other MEDICAL HISTORY Do you have any of the following? (check all that apply) Diabetes Hypertension Heart Disease Stroke Asthma / COPD Thyroid Disease Cancer Depression / Anxiety Arthritis Kidney Disease Epilepsy HIV / AIDS Hepatitis Osteoporosis Other: Previous Surgeries / Hospitalizations (list all) CURRENT MEDICATIONS & ALLERGIES Current Medications (name, dose, frequency) Allergies & Reaction FAMILY HISTORY Family history of: (check all that apply) Heart Disease Diabetes Cancer Stroke Mental Illness Hypertension Kidney Disease Thyroid Disease Other: LIFESTYLE Smoking: Never Former Curren Alcohol: None Occasional Regular Exercise: Sedentary Moderate Active REASON FOR TODAY'S VISIT Chief Complaint / Main Concern Additional Notes CONSENT & SIGNATURE I authorize Jensen Lakes Medical Centre and its physicians to provide medical care and to collect, use, and disclose my personal health information as necessary fortreatment purposes, in accordance with applicable privacy legislation (Alberta Health Information Act). Patient / Guardian Signature Date Health Card # Send
