Date

First Name

Middle Name

Last Name

Date of Birth

Address

Province

City

Postal Code

BC Health care number

Tel No:

Alternate Contact No:

Email

Previous / Present family physician

Previous / Present family physician Contact Details (tel):

Marital Status:

Occupation:

Retired

Are you on disability?:
—Please choose an option—YesNo

Educational status
—Please choose an option—KindergartenPHDMastersHome schoolingUniveristy / College degreeGrades

Do you have a legal problem (Please specify):

Are you vaccinated as a child
—Please choose an option—YesNo

Current Vaccination:

Please indicate active medical problems (Year/date & comments)

Past medical/psychiatric and surgical history (Details, Year/date & comments):

Current medications (Medication, Dosage & comments):

Allergies (Drug or non Drug & Nature of reaction)

Family history
DiabetesBreast cancerHypertensionBack pain/surgeryHeart attackOsteoporosisOsteoarthritisPCI/Heart surgeryStrokeSudden deathObesityProstate enlargementCrohn's diseaseLeukemiaLymphomaColitisThyroid dxAsthmaLung cancerStomach ulcerrenal dxCataractOther cancersOther dx

Women reproductive history:
Age of first periodPregnanciesMiscarriagesAbortionsHave you attained menopauseDo you have regular periodsLast past smearImplant/IUDAbnormal pap smearIrregular periodsBleeding between periodsPremenstrual syndrome

Social and lifestyle history:
Do you exerciseDo you like your weightDo you take cannabisDo you smoke tobacco/cigaretteDo you consume alcoholDo you use opiodsDo you take stimulantsDo you use benzodiazepines/tranquilizersDo you use street drugsOthers (please specify)