Follow Up Intake Questions Follow-up Intake Form Questions Patient Name(Required) First Last Health Card Number With Version CodeDate of Birth MM slash DD slash YYYY Please enter your most recent blood pressure reading if you have a home blood pressure machineHeight(Required)Weight(Required)Family Doctor Name(Required)Family Doctor Telephone(Required)Since your last visit with the doctor/nurse practitioner here, have you experienced: Chest Pain Palpitations (feeling fast heart beats) Shortness of breath (either when walking up a flight of stairs, or walking 3 blocks on level ground) Dizziness Fainting Spells Since your last visit at the clinic, have you been hospitalized?(Required) Yes No Please provide the name of the hospital and the reason for admission(Required)Please list all medications you take, including the dosage, and how often you take them. Please also list any inhalers and puffers you use on occasion, and any vitamins/supplements you take. *Even though we have a medication history on file, we require to re-verify everything the patient takes at every visit.*(Required)Please list any allergies you have. If you have no allergies, then write "NKDA"(Required)Please indicate which vaccinations you have received by checking all that apply. Flu Shot Shingles Shot Pneumonics Shot Covid Shots Do you see other doctors/specialists?(Required) Yes No Please list their names and their telephone numbers below(Required)
