Adult Intake Form (16 Years and Older) Step 1: Informed Consent NOTE TO CLIENT: We require your informed consent. This means we want you to understand the services we hope to provide to you and what we do with the personal Information we obtain about you. We work to provide you with health care services that meet your needs and enable you to seek those services at organizations across the province. In doing so we may need to share your personal health information via fax or an electronic sharing system with other health service providers who are involved in your care. Please read the following in its entirety and agree to the declaration at the end of this page before proceeding to fill out the patient intake form. ✓ I understand that I may access services at the Essex County Nurse Practitioner-Led Clinic. The type and extent of services, available options for services, and the risks and benefits of services have been explained to me. I have had the opportunity to ask questions about the services provided. ✓ I understand that I have specific rights and responsibilities related to my care. If I choose to participate in ongoing service I understand I will receive additional information about programs, services, privacy and safety. ✓ I understand that the agency will collect, use and disclose my personal health information for the purposes of referral, consultation, assessment and provision of services. ✓ I understand that an electronic sharing system may be used to share my personal information and/or prescription drug information history with other health service providers, who may need to review the data in order to provide services to me. I understand I may withdraw consent to sharing my assessment and/or prescription drug information in the electronic sharing system at any time. ✓ I also understand that this personal health information may be used and electronically shared with other individuals and service providers such as doctors, nurses, care givers, community care providers and other organizations involved in my care in order to provide the most comprehensive services possible. ✓ I understand that my use of services and my personal health information will remain secure and confidential. Disclosure of information to others outside those involved in my care will only be made with my consent. I further understand that there are specific exceptions to this confidentiality as explained to me. Note: The organization has a responsibility to report suspected and/or disclosed reports of abuse, neglect and/or intent to do harm to self or others. ✓ I agree that the information was provided to me in simple, easy to understand language and addressed my cultural beliefs and preferences. I declare I have read, understood and agree to the contents of the Informed Consent Agreement in its entirety. By submitting this form, I confirm I understand the purpose for which my personal health information is collected, used and shared and my privacy rights.NextStep 2: Personal Information Thank you for your interest in becoming a client at Essex Nurse Practitioner Led Clinic. The ECNPLC collects, uses and discloses personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). The priority of the ECNPLC is to provide primary health care services to residents who live in Essex and surrounding communities who do not have a primary care provider. Please answer the following questions to the best of your knowledge. Preferred Location Please select the ECNPLC location you are registering for: —Please choose an option—EssexWindsor (Drouillard)AmherstburgKingsville Personal Data Name: Date of Birth: Street Address: City/Town: Phone Numbers: Preferred: Alternate: Your Email: Do you consent to receiving email communication? This form of communication will not include any personal health information and is strictly one-way. You will not be able to email us. YesNo BackNextStep 3: Medical Information Do you currently have a primary care provider (Nurse Practitioner / Family Physician)? YesNo If yes, provide name and city of your provider: Health Card Number: Version Code: Exp Date: Emergency Contact Name: Emergency Contact Phone: Relationship: Name and location of the pharmacy you use: Specialist(s) you are currently seeing or have seen in the past: BackNextStep 4: Medical History Check off all that apply to you High blood pressureCoronary heart diseaseHeart attack (MI)Atrial fibrillation (A-fib)DiabetesHigh cholesterolThyroid problemsStroke or TIACOPD/Emphysema/AnginaSleep ApneaSmokerAsthmaChronic kidney diseaseAnxietyOsteopenia/osteoporosisOsteoarthritisDepressionDementiaSeizure DisorderReflux (GERD)Chronic painLow back painFainting (syncope)Hepatitis/TB/HIV Please list allergies to medications, food, or environment (penicillin, dust, pollen, dogs, etc.) Please list current medications, vitamins, and supplements (even if not used every day) or attach a copy of an up-to-date medication list from your pharmacy. Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNo BackNextStep 5: Social history Employment occupation: Employment Status: Full timePart timeSelf-employedUnemployedRetired Highest Education: No formal educationGrade schoolHigh schoolCollege/University Country of origin: Religious Affiliation: Marital status: MarriedCommon-lawDivorcedSingleOther Number of children: Number of people in the household: BackNextStep 6: Risk Factors Tobacco Use Do you smoke or use tobacco? NeverYes How much per day? Number of years: Are you a previous smoker that quit? NoYes How long ago did you quit? Alcohol Use Do you drink alcohol? NoYes Number of drinks per week: Is your alcohol use a concern for you or others? Drug Use Have you ever used drugs? NoYes Do you use recreational drugs? NoYes Have you ever used needles to inject drugs? NoYes BackNextStep 7: Lifestyle Diet How do you rate your diet? GoodFairPoor Do you eat or drink four servings of dairy or soy, or take calcium supplements daily? YesNo Do you eat all four food groups? YesNo How many meals per day? How many snacks per day? Do you consume caffeine? NoneCoffee, tea, soda How many cups/cans per day? Are you satisfied with your weight? YesNo Please explain: Exercise Do you exercise regularly? YesNo What kind of exercise? How long are exercise sessions? How often are your exercise sessions? If you do not exercise, what is holding you back? Sexual Activity Are you sexually active? YesNo Current sex partner(s): MaleFemaleBoth male and female How many sex partners do you currently have? Birth Control Method None neededCondomsPillPatchOther Have you ever had any sexually transmitted infections/diseases (STDs)? YesNoBackNextStep 8: Family History Please indicate if any blood relatives have suffered any of the following conditions. If yes, please indicate which family members (e.g. Parent, sibling, grandparent, and, uncle, etc.) had the condition. Alcoholism/Drug use? YesNo Who? High cholesterol? YesNo Who? High blood pressure? YesNo Who? Stroke? YesNo Who? Mental health problems? YesNo Who and what type? Diabetes? YesNo Who and type? Cancer Breast cancer YesNo Who? Lung cancer? YesNo Who? Prostate cancer? YesNo Who? Colon cancer? YesNo Who? Uterine/ovarian cancer YesNo Who? Have you had any previous hospitalizations, surgeries or injuries? YesNo If yes, please list the procedure and when. BackNextStep 9: Health Maintenance Screening I am: —Please choose an option—MaleFemaleOther Female Medical History Mammogram: Pap smear: Bone Density Test: Fit (fecal occult blood) Are you currently pregnant? YesNo Date of last normal menstrual period: Describe your menstrual cycle: Pregnancies Have you ever been pregnant in the past? —Please choose an option—YesNo How many pregnancies have you had? Have you had any miscarriages? Have you had any abortions? How many births? Any premature births? Do you experience any symptoms of menopause? If yes, date of onset and symptoms you experience: Do you experience urinary incontinence? If yes, state amount, frequency, and cause (if known): Male Medical History Please indicate if you experience any of the following: Difficulty starting to pee? Weak urine stream? Dribbling? Do you experience frequent urination at night? If yes, how many times do you get up? When was your last physical? When was your last blood test? When was your last colonoscopy? When was your last colon cancer Fit (fecal occult blood)? When was your last PSA blood test or rectal exam? When was your last bone density test? BackNextStep 10: Additional Information Immunizations Please list the date of your last immunization for the following or indicate NA if you have not had one: Tetanus: Shingles: Pneumonia: Flu: Hepatitis A Hepatitis B: Covid: Please list any other information or health concerns that you feel we should know. I understand that the information I have provided is accurate to the best of my ability. I understand that my information will remain private and confidential, only to be used by the medical personnel at ECNPLC. Back
