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.

    Step 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

    Personal Data





    Phone Numbers:


    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

    Step 3: Medical Information

    Do you currently have a primary care provider (Nurse Practitioner / Family Physician)?








    Step 4: Medical History

    Check off all that apply to you


    Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNo

    Step 5: Social history


    Employment Status: Full timePart timeSelf-employedUnemployedRetired
    Highest Education: No formal educationGrade schoolHigh schoolCollege/University


    Marital status: MarriedCommon-lawDivorcedSingleOther

    Step 6: Risk Factors

    Tobacco Use

    Do you smoke or use tobacco?


    Are you a previous smoker that quit?

    Alcohol Use

    Do you drink alcohol?

    Drug Use

    Have you ever used drugs?
    Do you use recreational drugs?
    Have you ever used needles to inject drugs?

    Step 7: Lifestyle

    Diet

    How do you rate your diet?
    Do you eat or drink four servings of dairy or soy, or take calcium supplements daily?
    Do you eat all four food groups?


    Do you consume caffeine?
    How many cups/cans per day?

    Are you satisfied with your weight?

    Exercise

    Do you exercise regularly?



    Sexual Activity

    Are you sexually active?
    Current sex partner(s):

    Birth Control Method
    Have you ever had any sexually transmitted infections/diseases (STDs)?

    Step 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?
    High cholesterol?
    High blood pressure?
    Stroke?
    Mental health problems?
    Diabetes?

    Cancer

    Breast cancer
    Lung cancer?
    Prostate cancer?
    Colon cancer?
    Uterine/ovarian cancer
    Have you had any previous hospitalizations, surgeries or injuries? If yes, please list the procedure and when.

    Step 9: Health Maintenance Screening

    I am:

    Female Medical History






    Are you currently pregnant?

    Describe your menstrual cycle:

    Pregnancies

    Have you ever been pregnant in the past?
    Have you had any abortions?





    Male Medical History


    Please indicate if you experience any of the following:





    Step 10: Additional Information

    Immunizations

    Please list the date of your last immunization for the following or indicate NA if you have not had one: