Medical Patient Information and Registration

Patient Information

First Name

Middle Name

Last Name

Date of birth*

Gender

Occupation

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Health care number*

Province*

Home phone*

Cell phone

Email

Emergency Contact

Name*

First Last

Phone

Relation to patient

Do you have extended medical benefits?

yes
no

Medical benefits provider information

Do you currently have a family doctor?

yes
no

Family Doctor

Family Doctor's Name*

First Last

Clinic name, address & phone*

Would you like your consult sent to your family doctor?*

yes
no

Medical History

Are you taking any prescription / non-prescription medication or supplements?

yes
no

Medications and supplements

Medication	Dosage

Do you have ANY adverse reactions or allergies to ANY medications?*

yes
no

Medications you have adverse reactions or allergies to

Aspirin
Codeine
Ibuprofen
Morphine
Penicillin
Sulfa
Other

Other allergies or adverse reactions to medications

Do you have any non-drug related allergies?*

yes
no

Nnon-drug related allergies?

Hay-fever
Latex
Food
Other

Other non-drug allergies

Do you smoke?

yes
no

What & how much per day?

Are you pregnant?

yes
no

Expected due date?

Please list any past surgical procedures

Procedure	Year

Current or past health issues

Other current or past health issues

Patient or guardian signature

If signing on behalf of the patient, please indicate name and relationship