New Consult Intake Questions New Consult Intake Questions Patient Name(Required) First Last Health Card Number With Version Code(Required)Date of Birth(Required) 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)Have you in the past year experienced the below? (select all that apply) 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 Have you had any previous operations or surgeries?(Required) Yes No Type of operation/surgery and approximate date(s):(Required)Have you ever had a heart attack?(Required) Yes No What year did you have the heart attack?(Required)Have you ever had a stroke?(Required) Yes No When did the stroke occur?(Required)Have you ever been diagnosed with heart failure?(Required) Yes No When were you diagnosed with heart failure?(Required)Have you had a heart stent placed?(Required) Yes No What year and at which hospital did you have the heart stent?(Required)Have you had heart surgery?(Required) Yes No What year, and which hospital did you have your heart surgery?(Required)Do you have any other medical conditions we should be aware of?(Required) Yes No Please list all other medical conditions you have(Required)Have you been hospitalized in the last year for any reason?(Required) Yes No What hospital did you go to, and what was the date that you went?(Required)Do you have diabetes?(Required) Yes No Are you currently taking any medications to manage it?(Required) Yes No Are you a smoker?(Required) Yes No I smoked, but I quit How long ago did you quit, or how old were you when you quit?(Required)What age did you start smoking?(Required)How many packs per day do you smoke?(Required)Do you snore when you sleep?(Required) Yes No Do you have sleep apnea?(Required) Yes No Do you use a CPAP?(Required) Yes No Have you been diagnosed with high blood pressure or do you take medications for blood pressure?(Required) Yes No Do you have high blood fats like high cholesterol or do you take medication for your cholesterol?(Required) Yes No Does anyone in your family have a history of heart disease, heart conditions, or heart surgeries?(Required) Yes No Which family member had the heart condition or surgery (ie. mom, dad, paternal uncle, maternal cousin, etc.)(Required)What specific heart condition or problem did they have?(Required)How old were they when the condition began?(Required)What is your marital status?(Required) Married Single Divorced Widowed Do you have children?(Required) Yes No How many children?(Required)123456789101112131415What is your occupation (if you are retired, what was your previous work)?(Required)Do you currently drink alcohol?(Required) Yes No What type(s) of alcohol do you usually consume? (e.g., beer, wine, spirits)(Required)How much do you typically drink at one time?(Required)How often do you drink alcohol?(Required)Please list all medications you are currently taking, including the name, dosage, and how often you take each one.(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 Pneumonia Shot Covid Shots Do you see other doctors/specialists?(Required) Yes No Please list their names, their specialty (ie. respirologist, oncologist, etc) and their telephone numbers below.(Required)What pharmacy do you use (or would you want the doctor to send a prescription to, if they need to write you one?). And what is the pharmacy contact info?(Required)
