ALondon Nurse Practitioner-Led Clinic, Health Zone

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New Patient Application Form

By initialing here I certify that the information below is correct to the best of my knowledge.

ByBy initialing here I acknowledge that completing this registration form does not guarantee that I will become a patient at the Health Zone Nurse Practitioner-Led Clinic.

By initialing here I acknowledge that I understand I will not become a registered patient until AFTER attending an intake appointment with a Nurse Practitioner wherein my health information will be reviewed and a final decision will be made whether the Health Zone Nurse Practitioner-Led Clinic will accept me as a patient based on the Nurse Practitioner scope of practice.

**Have you signed up at Health Care Connect Ontario for a Provider also?

Last Name:

First Name:

Date of Birth:

Gender:

Sex assigned at birth:

Pronouns:

Permanent Address:

Phone #:

Email:

OHIP#:

What is your source of income (employment, pension, social assistance)?

Do you currently have a primary health care provider (Nurse Practitioner/Physician)?

Yes

Is someone in your family already a patient at the Health Zone NPLC?

Yes

Are you currently on medication to manage a physical health concern?

Add Medication

Medication	Dose	Reason for Taking	Current Prescriber
Medication desk 0	Dose desk 0	Reason desk 0	Rrescriber desk 0
Medication desk 1	Dose desk 1	Reason desk 1	Rrescriber desk 1
Medication desk 2	Dose desk 2	Reason desk 2	Rrescriber desk 2
Medication desk 3	Dose desk 3	Reason desk 3	Rrescriber desk 3
Medication desk 4	Dose desk 4	Reason desk 4	Rrescriber desk 4

Add Medication

Current Pharmacy name:

Current Pharmacy address:

Physician Information

Do you, or have you ever seen any specialists (cardiologist, psychiatrist, etc.)?

Yes

Health and Social History:

What is your primary language?

Do you require a translator?

Yes

Immunizations

Allergies or Intolerances (Please include type of reaction as well)

Are all your immunizations up to date?

Yes

Tobacco Use:

Smoking cigarettes?

Yes

Alcohol Use:

Do you drink alcohol?

Yes

Drug Use:

Do you use cannabis?

Yes

Never

Do you use recreational or prescription drugs?

Yes

Never

Have you ever used needles to inject drugs?

Yes

Diet:

How would you rate your diet?

Good

Fair

Poor

Any dietary restrictions?

Are you having any issues with appetite or eating habits?

Yes

Have you experienced significant weight change in the last 2 months?

Yes

Sleep:

On average, how many hours do you sleep a night?

Are you having any issues with:

Poor quality sleep

Disturbing Dreams

Sleeping too late

Sleeping too much

Other

Legal issues

Have you ever experienced any of the following issues, please circle all that apply:

Difficulty	No	Yes
Depressed mood/anxiety	No_depressed	Yes_depressed
Panic attacks	No_panic	Yes_panic
Hallucinations	No_hallucinations	Yes_hallucinations
Body Image Problems	No_body_image	Yes_body_image
Repetitive behaviours	No_repetitive_behaviours	Yes_repetitive_behaviours
Suicidal thoughts/attempts	No_suicidal	Yes_suicidal

Difficulty	No	Yes
Mood swings	No_swings	Yes_swings
Phobias	No-phobias	Yes-phobias
Frequent Body Aches	No-body_aches	Yes-body_aches
Repetitive thoughts	No-repetitive_thoughts	Yes-repetitive_thoughts
Homicidal thought	No-homicidal	Yes-homicidal
If yes, when?

Have you experienced any of the following issues, please check all that apply:

**Reminder that each family member needs to fill out a separate application**.

Please list any persistent physical symptoms or health concerns:

Is there any family members that will be filling out an application also? Please list names below:

**Please note that completion of this application does not guarantee an appointment. Your application will be reviewed and you will only be contacted if we are able to accept the application based on the information given.