Physician Access Registry 700, Craig Nord Cookshire-Eaton (Québec) J0B 1M0 Telephone: 819 821-4000 FAX: 819 875-5565 HEALTH QUESTIONNAIRE FOR PEOPLE RESIDING IN THE HAUT-SAINT-FRANÇOIS AND IN NEED OF A FAMILY PHYSICIAN IDENTIFICATION Last Name First Name Address (number and street) Apartment City Province: Postal Code Home Telephone Work Telephone, Cell, or Other Email Address Health Insurance Number Expiration Date year month Birth Date Year Month Day Age Man Woman * and ** * Patient aged 40 years and over Would you like to be contacted by the «Clinique de transition» of CLSC Cookshire to have a preventive medical exam by a clinical nurse? No Yes Date of last blood test : *Patient aged 25 years and over Would you like your name to be added to the waiting list for a «Pap test» (gynecological test administered by a clinical nurse at the CLSC)? No Yes Year of most recent «Pap test» SPECIFY YOUR NEEDS FOR ACCESS TO A PHYSICIAN Do you currently have a family physician? No Yes Name of Physician City/Location of Physician s Practice Have you ever had a family physician? No Yes Name of Physician City/Location of Physician s Practice If yes, please provide the reason for the discontinuation of the family medicine services Which walk-in clinic do you normally visit? Do you see a specific physician there? Physician Clinic City/Location of clinic HSF - Guichet d accès/access Registry 2016-01-16 Page 1 of 6
HEALTH ASSESSMENT: DIAGNOSED PROBLEMS KEY : Specify the year you received the diagnosis CANCER Type: Type: Undergoing treatment Undergoing treatment HEART AND VASCULAR PROBLEMS High blood pressure MCAS (angina) Cholesterol problems Heart failure Cerebral vascular accident (CVA) Infarct Aftereffect(s) of CVA List them: Taking Coumadin? For life Reason: MENTAL HEALTH PROBLEM Depression with prescription Schizophrenia Anxiety problems with prescription Bipolar Disorder Depression without prescription Adjustment Disorder Psychosis DIABETES Treated with insulin Treated by diet, without medication Treated with oral medication CHRONIC INFLAMMATORY DISEASE Rheumatoid arthritis Collagenosis Psoriatic arthopathy Ulcerative colitis Lupus Crohn s Disease Scleroderma THROMBOEMBOLIC DISEASE RELAPSES (requiring anticoagulant therapy e.g. Coumadin) Pulmonary embolism and newly diagnosed thrombophlebitis Medium- or Long-term anticoagulation PULMONARY PROBLEM Chronic Obstructive Pulmonary Disease (COPD) Oxygen at home Asthma HIV/AIDS AIDS/HIV infection newly diagnosed HIV infection controlled with medication DEGENERATIVE DISEASE OF CENTRAL AND PERIPHERAL NERVOUS SYSTEM Epilepsy Parkinson s Disease Amyotrophic Lateral Sclerosis Alzheimer s disease Dementia Multiple Sclerosis GMF HSF Formulaire Guichet d accès/access Registry Mise à jour: 2016-01-15 Page 2 de 6
HEALTH ASSESSMENT: DIAGNOSED PROBLEMS (cont d) KEY : Specify the year the diagnosis was made RENAL DISEASE (kidneys) Chronic kidney failure Dialysis LIVER DISEASE Hepatitis A Hepatitis C Hepatitis B Cirrhosis MUSCULOSKELETAL DISEASE Lumbago (lower back problem) Fibromyalgia Osteoarthritis Osteoporosis THYROID PROBLEM Hyperthyroidism Hypothyroidism DIGESTIVE PROBLEM Ulcer Acid reflux Irritable bowel syndrome SKIN PROBLEM Cancer Eczema Psoriasis Zona OTHER (specify any diagnosed problems not listed above) MEDICATION INFORMATION Do you need to take any prescription drugs, patches or use pumps on a regular basis? No Yes Name of Pharmacy: Medication to be renewed on: *Attach the list of medications provided by your pharmacist to the form LIST OF YOUR MEDICATIONS Name of Medication Dosage Frequency In the event where your file is prepared to be assigned to a family physician or the access clinic, do you hereby authorize the pharmacist to forward your list of medications by FAX? No Yes GMF HSF Formulaire Guichet d accès/access Registry Mise à jour: 2016-01-15 Page 3 de 6
HOSPITALIZATIONS/CONSULTATIONS INFORMATION During the past year, have you consulted a specialist? No Yes, please specify: Name: Speciality: Name: Speciality: Nam: Speciality: City: Reason: City: Reason: City: Reason: During the past year, have you been hospitalized? No Yes. If yes, complete the following section. Location: Cause(s): During the past year, have you gone to an Emergency department? No Yes. If yes, complete the following section. Location: Cause(s): Presently, are you receiving CLSC services? No Yes, which ones? Home care Medical services Nursing care at the CLSC Psychosocial services MOBILITY/AUTONOMY Autonomy Limited Not autonomous Technical aids, specify: Can you get to and from consultations? Yes No, for which reason(s)? Lack of transportation Lack of mobility Other: FAMILY DESEASES (father, mother, brothers and sisters) GMF HSF Formulaire Guichet d accès/access Registry Mise à jour: 2016-01-15 Page 4 de 6
COMMENTS DECLARATION I hereby declare that all statements/declarations and information provided in this application and any related supporting documents are true. Signature: Date: (Signature of the person, or of his or her legal representative) Title of Legal Representative: (Father, mother, tutor, curator or mandatary) AUTHORIZATION FOR THE REFERENCING AND FORWARDING OF MEDICAL INFORMATION I consent to all heath etablissements or pharmacies to follow my medical file and my list of medications who those in charge of the GMF du Haut-Saint-François Family Physician Access Registry. I consent to allow those in charge of the GMF du Haut-Saint-François Family Physician Access Registry to collect, use and divulge the information provided on this questionnaire as well as the information contained in my GMF du Haut-Saint- François medical record to the family physician who agrees to accept me as a patient or the physician with whom I will have a consultation at the access clinic. Signature: Date: (Signature of the person, or of his or her legal representative) Title of Legal Representative (Father, mother, tutor, curator or mandatary) GMF HSF Formulaire Guichet d accès/access Registry Mise à jour: 2016-01-15 Page 5 de 6
IF YOU NEED URGENT MEDICAL CARE, GO TO THE HOSPITAL EMERGENCY OR CALL 811 (INFO SANTÉ) From now on, if there are changes to your state of health, address or telephone number, please complete the form: «Changes to My Medical Condition, My Address or My Telephone Number» available at the reception desk of CLSC Cookshire, Weedon, La Patrie or East Angus Once the form is duly completed, there are three ways to return it to us: By Postal Mail: GMF du Haut-Saint-François Family Physician Access Registry CLSC Cookshire 700, rue Craig Nord Cookshire-Eaton (Québec) J0B 1M0 By FAX: 819 875-5565 In Person: Take it to the reception desk at the CLSC Cookshire, Weedon, La Patrie or East Angus GMF HSF Formulaire Guichet d accès/access Registry Mise à jour: 2016-01-15 Page 6 de 6