New Patient Application Form

Do you currently have a primary health care provider (Nurse Practitioner/Physician)?
Provide your previous Physician or Nurse Practitioner's name and address:
Provide the Physician or Nurse Practitioner's name and address:
Is someone in your family already a patient at the Health Zone NPLC?
Provide their full name(s):
Add family member
Are you currently on medication to manage a physical health concern?
Add Medication
MedicationDoseReason for TakingCurrent Prescriber
Add Medication

Physician Information

Do you, or have you ever seen any specialists (cardiologist, psychiatrist, etc.)?
Provide name and phone numbers:
Add Specialist

Health and Social History:

Immunizations

Are all your immunizations up to date?

Tobacco Use:

Smoking cigarettes?
If yes:

Alcohol Use:

Do you drink alcohol?
If yes:

Drug Use:

Do you use cannabis, recreational or prescription drugs?
If yes:

Diet:

How would you rate your diet?
Are you having any issues with appetite or eating habits?
If yes:
Have you experienced significant weight change in the last 2 months?

Sleep:

Are you having any issues with:

Legal issues

Have you ever experienced any of the following issues, please circle all that apply:
DifficultyNoYes
Depressed mood/anxiety
Panic attacks
Hallucinations
Body Image Problems
Repetitive behaviours
Suicidal thoughts/attempts
DifficultyNoYes
Mood swings
Phobias
Frequent Body Aches
Repetitive thoughts
Homicidal thought
Have you experienced any of the following issues, please check all that apply:
RespiratoryCOPD
Asthma
Other
HeartHigh blood pressure
High cholesterol
Heart attack
Other
GynecologyEndometriosis
Ovarian cysts
Other
EndocrineDiabetes
Thyroid dysfunction
Other
Mental HealthAnxiety
Depression
Post Traumatic Stress Disorder (PTSD)
Other
SkinEczema
Psoriasis
Other
GastrointestinalIrritable Bowel Syndrome
Liver/Gallbladder concerns
Colitis
Other
Joints/MusclesBroken bones
Arthritis
Other
KidneyKidney Stones
Urinary Tract Infection
Other
NeurologyStroke
Migraine
Seizure
Other

**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.