COVID-19 Provincial restrictions March 29 - April 19

COVID-19 Provincial restrictions March 29 - April 19

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NEW PATIENT

Your first visit

iHealthMD is experiencing unprecedented demand for Family Physician services in North Vancouver. Several other practices have either closed or reduced their services due to the COVID-19 pandemic. This has created a surge of applicants and space is limited.

If you are interested in becoming a New Patient of iHealthMD then please fill out the brand new web-based application form. Your information will be forwarded to us directly.

SUBMITTING AN INTAKE FORM DOES NOT GUARANTEE WE WILL BE ABLE TO FIND YOU A FAMILY PHYSICIAN.

We ask that you do not call our office or send emails enquiring about the status of your application. You will be contacted in due time by email or phone when your application comes up for review.

In the meantime, for any urgent health concerns or for prescription refills please use our Walk-In Service.

New patient intake form

Previous Family PhysicianYesNo

Name of Physician

Your preference for Doctor*
First available doctorDr GoldsteinDr.MotaDr.Oveisi

Personal Information

First Name*

Last Name*

Preferred name

Birthdate (DD/MM/YYYY)*

Cell Phone*

Home Phone

Email*

Do you consent to email correspondence?
YesNo

Address*

Street*

City*

Postal Code*

Country*

Do you have a BC Personal Health Number* YesNo

Current Gender Identity?

MaleFemaleTransgender Male/FTMTransgender Female/MTFAdditional CategoryDecline to answer

What sex were you assigned at birth?

MaleFemaleOtherDecline to answer

Emergency Contact

Name

Number

Relationship

Social History

Home(who do you live with?)

Education

Work

Interests/Hobbies

Family members attending iHealthMD

Medical History

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

Medical Diagnosis

Year of diagnosis

Specialist Involved

Speciality

Surgical History

(including colonoscopy & gastroscopy)

Surgical Procedure

Year of procedure

Surgeon

Location of procedure

Everyday Living

Do you need assistance for mobility? YesNo

Do you use any home assistance/care services? YesNo

Do you have any advanced care planning in place? YesNo

Family Medical History (in 1st degree relatives)

Breast Cancer YesNo

Family member, Age of diagnosis

Bowel Cancer YesNo

Family member, Age of diagnosis

Cardiovascular Disease (heart attack and/or stroke) YesNo

Family member, Age of diagnosis

Prostate Cancer YesNo

Family member, Age of diagnosis

Diabetes YesNo

Hypertension (high blood pressure

Melanoma (skin cancer)

Prescription Medications

Medication: name, dose, frequency

Non-Prescription Medications

Medication/Supplement: name, dose, frequency

Medication Allergies

Medication: name, reaction

Risk Factors

Smoking YesNo

How many days per week do you exercise for 30mins or more? days

How do you feel about your nutrition? Healthy & balancedNeeds improvement

Are you vegan or vegetarian? YesNo

How many days per week do you drink alcohol? days

Do you use recreational substances (including THC and CBD)?

Height (cms)

Weight (kgs)

Preventative Medicine

Have you had a complete physical exam within the last 6months? YesNo

Are childhood vaccinations up to date?(please list the date you last had the following, if not applicable write n/a) YesNo

Tests

Pap smear DateN/A

Date

Mammogram DateN/A

Date

FIT (stool test for colon cancer screening) DateN/A

Date

Colonoscopy DateN/A

Date

Bone mineral density DateN/A

Date

Full body skin check DateN/A

Date

Vaccinations

Flu DateN/A

Date

Pneumonia DateN/A

Date

Tetanus (ADT) DateN/A

Date

Shingles DateN/A

Date

Whooping Cough (boostrix/adacel) DateN/A

Date

About us

We are a multidisciplinary medical clinic located in North Vancouver, accepting new patients for a variety of medical services including but not limited to Family Medicine, Primary Dermatology and Musculoskeletal Medicine.

NEW PATIENT

Your first visit

New patient intake form

Personal Information

Address*

Do you have a BC Personal Health Number* YesNo

Current Gender Identity?

What sex were you assigned at birth?

Emergency Contact

Social History

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

Surgical History (including colonoscopy & gastroscopy)

Everyday Living

Family Medical History (in 1st degree relatives)

Prescription Medications

Non-Prescription Medications

Medication Allergies

Risk Factors

Preventative Medicine

Tests

Vaccinations

Medical History

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

Surgical History

(including colonoscopy & gastroscopy)