General Medical History Form

CLIENT INFORMATION

First Name

Middle Name

Last Name

Sex

Male

Female

Date of Birth

Phone/Mobile

Residential Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Emergency Contact Name

Relationship

Phone/Mobile

Primary Care Physician (if applicable):

Phone Number

MEDICAL HISTORY

Current Health Concerns:

Allergies:

No known allergies

Yes (Please specify):

List all known allergies:

Medications (Include supplements and over-the-counter drugs):

Please specify your past medical conditions:

Surgeries and Hospitalizations

Date	Reason

Family Medical History:

LIFESTYLE & HABITS

Do you use recreational drugs?

Yes

Please specify the recreational drug(s) that you use:

Do you consume alcohol?

Yes

How often do you consume alcohol per day?

Do you smoke?

Yes

How many do you smoke per day?

IMMUNIZATION

Vaccination History

	Vaccinated 10+ yrs ago	Vaccinated within 10 yrs	Vaccinated Recently (this year)	Not Sure	Never Received
Tetanus
BCG
Diphtheria
Pertussis
Influenza
Pneumococcal
Meningococcal
Measles
Mumps
Rubella
Varicella (Chicken Pox)
HPV
Herpes Zoster (Shingles)
Rotavirus
Polio

Please upload any relevant immunization document(s) or photo(s) if you have any:

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AGREEMENT & CONSENT

I have read and agree to the Terms and Conditions, Privacy Policy and EHI Collection Policy.

I verify that the information entered in this form is true and correct to the best of my knowledge. By signing below, I confirm the accuracy of the provided information, consent to its use in my medical care, and acknowledge that I have read and agree to the Terms and Conditions and Privacy Policy.

Signature

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Today's Date

173-7181 Yonge Street, Thornhill ON L3T 0C7
Phone: (647) 955-6831
Fax: (647) 696-2942
Email: info@tmehealthcare.ca