Annual Physical Intake Questionnaire

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Annual Health Questionnaire

Annual Physical Intake Questionnaire

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2.*Please provide your OHIP number and version code if you have one? This will ensure we accurately identify you.

3.*Please indicate your family history, such as heart disease,cancers or diabetes. Please indicate who has had these illnesses and cause of death of close relatives.

4.*Please indicate if you drink alcohol, the type and quantity? Please be honest. If you believe you need to cut down please bring this topic up.

5.*Pleaae indicate if you smoke- or if you have smoked in the past please indicate how much you smoke ad if you are ready to quit. If you wish to quit please pick a quit date and select a potential support system if needed- nicotine, zyban

6.*Please indicate what tests you would like to have? chest xray, mammogram if female, bone density, ultrasound etc., bloodwork is routinely done and we advise occult blood testing of stool -aged 50-74 annually -called fecal occult blood

7.*Please indicate allergies if any. If none state none

8.Please state all operations you have had?

9.Please indicate if you believe you gamble, that includes lottery tickets excessively- please describe if relevant-

10.*Please indicate if you currently use illicit drugs and describe which type and how many

11.Please state if you have a problem with your weight- under or overweight. Please state the diets if any you have tried if you have tried to lose weight

12.*Please list your current medical illnesses- diabetes, high blood pressure etc if none state none

13.Please indicate your current symptoms and concerns-if none state none

14.Please indicate the level of exercise and type you undertake per week?

15.Please indicate your vaccine history Tetanus every 10 yrs Pneumovax over 65 and high risk groups



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