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Comprehensive Profile

This form is necessary to fill out accurately so as to get a complete and detailed record of you as a patient
(please do not miss any fields).

***All of your information is kept strictly confidential.***

Vaughan Medical Centre, 9200 Weston Rd, Woodbridge, ON, L4H 2P8 (905) 417-2273 (CARE)

First Name: Last Name:
Home Phone:    

 

Major Complaint(s) and in order of importance for you?

Complaint(s):
Since:
Causes:


What medications are you currently taking?

Medication(s):
Since:
Adverse effects:


What other treatments/regimens are you currently following?

Treatment(s):
Since:
Results:


What Hospitalizations or surgeries have you had?

Surgery/Hospital:
When:
Complications:


Which of the following conditions have you had?

Abcesses Hayfever Prostatitis
Alcoholism Heart Disease Rheumatic Fever
Allergies Hepatitis Rubella
Amnesia Herpes Genitalia Scarlet Fever
Angina Hernia Sciatica
Arthritis Hypoglycemia Sexual Abuse
Asthma High blood Pressure Skin Disease
Bronchitis Influenza Strep Throat
Chicken Pox Kindey Stones Sinusitis
Cold Sores Leukemia Small Pox
Colitis Malaria Sunstroke
Depression Measles Stroke
Diabetes Meningitis Syphilis
Diptheria Miscarriage Tonsillitis
Emphysema Mononucleosis Tuberculosis
Epilepsy Mumps Typhoid Fever
Frequent Colds Neuritis or Neuralgia Thyroid problems
Gall Stones Painful/Achy Joints Venereal Warts
Gastritis Pancreatitis Warts
Goitre Parasites Whooping Cough
Gonorrhea Pelvic Infl. Disease Worms
Gout Peritonitis Yellow Fever

Any other Major Conditions/Surgery?:


Are there any of the preceding conditions after which you have never been totally well again, or which have been more severe than usual? Yes No

Which ones?


What Major Injuries have you had?

Injury(s):
When:
Long term effects:


How much of the following substances are you using?

Tobacco: Alcohol:
Coffee: Recreational drugs:

Age of first menses:

What vaccinations have you had?


Check off any immunizations you have received:

Polio DPT
MMR Small pox
Chicken pox Hepatitis
Tetanus    

Any adverse effects from the above? Yes No

Allergies:

What exercise do you do and how much?

Indicate below, which of the following ailments, or any other major ailments have
affected your relatives:

Alcoholism Gout
Allergies Hay Fever
Arthritis Heart Disease
Asthma Insanity
Cancer Paralysis
Depression Pneumonia
Diabetes Skin Disease
Epilepsy Syphilis
Gonorrhea Tuberculosis

Relative:
Age if alive:
Age at death:
 Ailments:
Mother
Father
Brother(s)
Sister(s)
Children
Maternal Grandmother
Maternal Grandfather
Maternal Aunt(s)/Uncle(s)
Paternal Grandmother
Paternal Grandfather
Paternal Aunt(s)/Uncle(s)


Are you currently under the care of another physician? Yes No

Physician:
For what Condition(s):
 Treatment:

If not then why?

What medications do you regularly take?

Digestive enzymes Antacids
Blood pressure pills Sedatives
Sleeping pills Thyroid medicine
Painkillers Megavitamins
Laxatives Hormone replacement
Herbs Cortisone
Birth control pills    

Anything else?:

What habits/lifestyle do you have?:

Awaken refreshed Have trouble relaxing
Have trouble sleeping Have problems at work or home
Feel stressed often Get constipated often

 

"By checking this box, I affirm that all the above information I have provided is as accurate as possible."

I Agree.

 

 

 
Vaughan Medical Centre 2009-2010