Patient Application Form – East St. Paul Medical Center

Date / Time

Date

Time

Patient Information

Full Name (This must match what is listed on your MB health card) *

First

Last

PHIN (9 digit number)

MHSC (6 digit number)

Address *

Address Line 1

City

State / Province / Region

Country

Home Phone

Date of Birth

Email Address *

Cell Phone *

Preferred Gender *

Past Medical History

Please Check All That Apply

Allergies *

Medications *

Surgeries

Family History

Immunization History

Screening History

If you are 50 years old or older, have you ever been screened for:

Health and Lifestyle History

Do you Smoke?

Yes
No

How Many Packs Per Day?

What age did you start?

Have you ever quit?

Yes
No

Are you concerned about your Alcohol use?

Yes
No

If you answered "Yes" for yourself, please answer the next four questions

Have you ever felt you should cut down on your drinking?

Yes
No

Have people annoyed you by criticizing your drinking?

Yes
No

Have you felt guilty about your drinking?

Yes
No

Have you ever had a drink first thing in the morning to calm yourself or get rid of a hangover?

Yes
No

Health and Lifestyle History Continued

Do you often have the feeling of being overwhelmed or depressed?

Yes
No

Have you ever sought the help of a counsellor or therapist?

Yes
No

On average, how many hours of sleep do you get per night?

Do You Exercise?

Yes
No

Please provide an example of what you eat on any given day

If Yes, What type of Exercise? How often?

Do you drink caffeinated beverages?

Yes
No

What are your personal health goals? (This can be physical, mental, spiritual, or emotional)

How many cups/cans/glasses per day?

Sexual History

Have you ever been sexually active?

Yes
No

Are you currently sexually active?

Yes
No

Complete the following questions if you answered "yes" to the questions above:

Gynecological History (if applicable):

Date of Last Pap Smear

Results of last Pap Smear (if known):

Have you ever had an abnormal pap smear?

Yes
No

If Yes, explain what was done for further investigation and/or treatment:

Number of Pregnancies

Are you presently trying to become pregnant or will be trying soon?

Yes
No

Do you feel that any of the above symptoms are urgent and require prompt evaluation?

Yes
No

If yes, which symptom(s):

Other Information

If you have any other information you feel the doctor needs to know

Consent and Acknowledgment

Consent to Proceed *

I hereby give my consent to undergo the health screening as described above.

Privacy Acknowledgment *

I acknowledge that I have read and understand the privacy policy concerning the handling of my personal health information and agree to the use of my data in accordance with this policy.

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Signature

Clear Signature