Medical Questionnaire Questionnaire Erase & Resubmit Questionnaire As a current patient of Summit Health, we have the medical questionnaire on file that was completed for your last visit. I confirm there has been no change to my health or medication since my previous visit to Summit Health. Confirm Fill In New Questionnaire Demographic Information First Name* First Name is a required field Last Name* Last Name is a required field Birthdate* Birthdate is a required field Health Card Number Occupation Country Canada USA Other Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon State* state is a required field. Email* Email is a required field Phone* Phone is a required field Preferred Language English French Street* Street is a required field City* City is a required field Zip Code* Zip Code is a required field. Postal Code* Postal Code is a required field. Medical Information Do you have or have you ever been told that you have a cardiovascular disease?* None High Blood Pressure Heart Failure Arrhythmia Angina Aneurysm Heart Attack Bypass/stents Stroke/TIA Pulmonary Embolism Claudication DVT/Blood Clot Other Other Have you experienced any of the following symptoms in the past year?* None A productive cough for more than 3 weeks Hemoptysis (coughing up blood) Unexplained weight loss Fever, Chills, or night sweats for no known reason Persistent shortness of breath Unexplained fatigue Have you ever had a positive TB skin test?* No Yes When was your positive TB skin test Have you ever been in close contact with anyone who was sick with TB?* No Yes When were you in contact with someone with TB Have you ever been vaccinated with BCG (Bacillus Calmette–Guérin)?* No Yes If yes, when were you vaccinated Why do you require a TB Skin Test? Do you have any allergies?* No Known Allergies Yes Seasonal Allergies Allergies Have you ever been told that you have a pulmonary condition/respiratory illness?* None COPD Sleep Apnea Emphysema Chronic Bronchitis Asthma Pulmonary Fibrosis Other Other Do you have a digestive condition/gastro-intestinal illness?* None Irritable Bowel Syndrome Crohn's disease Colitis Gastric Reflux Other Other Do you have a liver disease? Have you ever had a hepatitis infection?* None Hepatitis A Hepatitis B Hepatitis C Other Other Have you ever had kidney issues or have you been diagnosed with a kidney illness?* Yes No Please Specify Have you ever been diagnosed with cancer?* Yes No Please Specify Have you ever experienced or been diagnosed with a neurological disorder? * None Epilepsy Convulsions or Seizures Meningitis Cerebral Malaria Other Other Have you ever experience or been diagnosed with a psychiatric disorder?* None Depression Anxiety Bipolar Schizophrenia Burnout/Medical Leave of Absence Other Other Do you presently have any skin disorders?* None Psoriasis Eczema Other Other Are you presently or have you ever been immunosuppressed (impaired immune system)?* None Due to Medication Hereditary Conditions Splenectomy HIV AIDS Other Other Have you ever been diagnosed with diabetes?* Yes No Please Specify Do you have any chronic or acute conditions, disorders or illnesses that were not mentioned above?* This is a required field Maternity status None I am pregnant I am planning a pregnancy I am breastfeeding Do you take any regular medications? If yes, please include all prescription medications, puffers/inhalers, herbal supplements and over-the-counter medications?* This is a required field Have you received all of your childhood vaccines? Yes No In which province/country did you receive your childhood vaccines? Do you live or work in close contact with the following populations? None Babies/Children Elderly Someone With A Chronic Illness Have you ever had an adverse reaction to a vaccine? None Anaphylactic Shock Vasovagal Other Other Do you smoke cigarettes? Yes No Sleep Symptoms Select the symptoms that correspond to your current situation:* Snoring Restless sleep Daytime drowsiness Night sweats Observed respiratory arrest Memory loss Tired upon awakening Irritability Headache in the morning Lack of concentration Difficulty breathing at night Jaw pain Choking with awakening during sleep Grind your teeth or clench your jaw Frequent awakening Non-restorative sleep Lifestyle Information Have you ever been diagnosed with diabetes?* Tobacco Have you ever smoked?* No Yes Are you still smoking?* No Yes How many cigarettes per day? This is a required field How many years have you been smoking? This is a required field How long have you stopped smoking? (if applicable) This is a required field Alcohol Do you drink alcohol (wine, beer and/or spirits) on a regular basis?* No Yes If so, at what time of the day?* Lunch Dinner Evening Number of drinks per week:* This is a required field Drugs Do you use drugs (including sleeping pills)?* No Yes If so, what drugs:* This is a required field Referrer Information If you were referred by your doctor or dentist, please provide their information so we can share your results directly with them. If you were not referred but would still like us to send your results to them, please fill in their name and we would be happy to accommodate your request. Doctor's First Name Doctor's Last Name Dentist's First Name Dentist's Last Name Please Specify Your Referrer Please select your referrer from the list below so that we can accurately send them your results when your test has been completed. Sleep Screening Is it possible that you have Obstructive Sleep Apnea (OSA)? The STOP BANG questionnaire is a proven screening tool that is used to find the likeliness for obstructive sleep apnea (OSA). These questions will help determine if you are low, moderate or high risk group for sleep apnea. Do you snore loudly? Louder than talking or loud enough to be heard through closed doors NO YES Do you often feel tired, fatigued, or sleepy during the daytime? NO YES Has anyone observed you stop breathing during sleep? NO YES Do you have (or are you being treated for) high blood pressure? NO YES BMI kg cm Age ≤50 years >50 years Neck circumference (cm) Gender Female Male The Epworth Sleepiness Scale assesses your level of daytime sleepiness and can determine if a meeting with a sleep specialist is warranted. The questionnaires asks you to grade the your probability of falling a sleep (on a scale of 0 to 3) during 8 routine activities. Tallying up these scores gives you your level of daytime sleepiness. No chance of dozing Slight chance of dozing Moderate chance of dozing High chance of dozing Sitting and reading Watching TV Sitting inactive in a public place (e.g a theatre or a meeting) Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol As a passenger in a car for an hour without a break In a car, while stopped for a few minutes in traffic Destination Information Please add all of the countries you will be visiting by searching below and clicking "add country to list" Country This is a required field Cities Visited This is a required field Days In Country This is a required field Add Country To List Trip Information Departure Date departure date is a required field Purpose of Trip Visiting Family/Friends Pleasure Holiday Business Volunteer Work Academic Adoption Possible Activities Climbing/High Altitude Extreme Sports Farming Healthcare Jogging/Bicycling Other Other Travel Accommodations All-inclusive resort Family/Friends Hotel Camping Villa Hostel Apartment Other Other Emergency Contact Emergency Contact Name This is a required field Emergency Contact Number This is a required field Parent or legal guardian name, if applicable Pharmacy Information Please provide the information of your pharmacy so that we can send prescriptions directly to your pharmacy (Optional) Pharmacy Name Pharmacy name is a required field Pharmacy Street Pharmacy address is a required field Pharmacy City Pharmacy city is a required field Pharmacy Fax Pharmacy fax is a required field I declare that all the information provided above is complete and accurate to the best of my knowledge. I understand that any false information could be detrimental to my health. I agree with the website privacy policy and the personal information policy. I understand and agree that the services prescribed by professionals who work at the clinic may also be found in other locations and that I am free to take the services offered here or at any other facility of my choice. I declare that all the information provided above is complete and accurate to the best of my knowledge. I understand that any false information could be detrimental to my health. I agree with the website privacy policy and the personal information policy I am aware that all vaccines and medications discussed during consultation are recommendations and are not requirements, unless otherwise specified on the Government of Canada Travel website (ex. Yellow Fever entry requirements). I understand that I am responsible for all pertinent information regarding my necessary travel documents and visa(s) requirements. I am aware that it is recommended that I remain in the clinic for 15 minutes post-vaccination. I understand that I am responsible for the proper handling of all medication and vaccines purchased for later consumption (Ex: Dukoral and Vivotif). I understand that these vaccines must be refridgerated between 2-8 degrees celcius at all times. I am aware that consultation fees and vaccination fees apply to all visits. I understand that the payment of these fees is due at the time of my appointment, and that all payments must be made by card (Credit Card or Interac). I agree to receive the results of my COVID-19 test by email. I confirm that the test results should be sent to the email address indicated above. Paladin Security I consent to Summit Health sharing my medical and immunization records with the organization responsible for covering the costs of my services, as per the data sharing agreement between Summit Health and the organization. This consent is limited to the specific services funded by the organization. Add Your Immunization Record Please take a photo or upload a file with your existing immunization record to help make your appointment as efficient as possible. Please bring your immunization record with you to your appointment I agree to the terms and conditions above You must agree before submitting. Submit Submitting Questionnaire ...
