Westheights Family Practice
Dr. Waseema Rehman Dr. Emil Khalil
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Westheights Family Practice
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Registration
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Westheights Family Practice
Patient Registration Form
Surname
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First Name
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Middle Name
Preferred Name
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of email between the physician and me, and consent to the conditions outlined herein, as well as any other instructions that the physician may impose to communicate with patients by email. I acknowledge the physician’s right to, upon the provision of written notice, withdraw the option of communicating through email. Any questions I may have had were answered.
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I Agree to the above conditions
Demographic Information
Birthdate (MM-DD-YYYY)
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Gender
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Male
Female
Other
Street Address
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City
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Province
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Postal Code
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Email
Health Card number
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Version Code
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Home Phone number
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Business Phone Number
Mobile Number
Marital Status
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Do you have Children (Y/N) How Many ?
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CURRENT MEDICATIONS
Do you currently take any prescribed medications
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Yes
No
If Yes, Please Provide List and Pharmacy information so we can obtain the list of Medications.
Pharmacy Name & Address
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List of Medications
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Please check 'I Agree' to confirm that all of the information provided above is true and that your give Westheights Family Practice consent to contact your pharmacy for your medications information.
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I Agree
Birth Control Pill is the only medication I am currently taking
Select
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Yes
No
Family Medical History
Father Side
Diabetes
High Blood Pressure
Cancer
Heart Disease
Mental Illness
AutoImmune Disease
Blood Disorders
Others
If Yes to any of above then please provide details
Mother Side
Diabetes
High Blood Pressure
Cancer
Heart Disease
Mental Illness
AutoImmune Disease
Blood Disorders
Others
If Yes to any of above then please provide details
PAST MEDICAL HISTORY
Have you had surgery in the past?
Please tell us other past medical issue you might think it is important for us to know
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Do yo have allergies?
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Yes
No
If Yes - Provide details
When was your last Mammogram? ( Female over the age of 50)
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When was your last Pap Smear (Female between the ages of 21-69 years old)
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When was the last time you did the Fecal Occult Blood test for Colon Cancer Screening (over the age of 50)
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CURRENT MEDICAL PROBLEMS
Please tell us about your current medical problems or conditions
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RISK FACTORS
Do you Smoke
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Yes
No
Regular exposure to second hand smoke ?
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Yes
No
Ex-smoker
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Yes
No
Do you drink ?
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Yes
No
Do you use drugs
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Yes
No
Do you gamble
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Yes
No
Disclaimer: The information stated in this form is for the purpose to create a Medical Record in our system. Later you will be requested to sign the regulatory forms from the Ministry of Health in order for you to become a patient at our practice.
Prove that you are not computer
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