YesNo



    Dr.GoldsteinDr.BrennanDr OveisiFirst available doctor


    Personal Information








    Address*




    Do you have a BC Personal Health Number* YesNo

    Current Gender Identity?

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    What sex were you assigned at birth?

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    Emergency Contact





    Social History







    Medical History

    (including diabetes, airways disease, heart failure, hypertension, neurological conditions, mental health)

    Surgical History

    (including colonoscopy & gastroscopy)

    Everyday Living

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    YesNo
    YesNo


    Family Medical History (in 1st degree relatives)

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    YesNo

    YesNo

    YesNo

    YesNo


    Prescription Medications

    Non-Prescription Medications


    Medication Allergies


    Risk Factors

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    days

    Healthy & balancedNeeds improvement

    YesNo

    days


    Preventative Medicine

    YesNo

    (please list the date you last had the following, if not applicable write n/a) YesNo

    Tests

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    Vaccinations

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    DateN/A

    DateN/A