Imana Intake Form

Dr. Mohammed Imana New Patient Intake

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Date of Birth (dd/mm/yyyy) *

Parent/Guardian Name (if applicable) *

Health Card Number *

Version Code *

Gender (as it appears on your driver's licence) *

Male Female Other

Existing Medical Conditions (write N/A if not applicable) *

Past Surgeries or Procedures (please include dates, or write N/A if not applicable) *

Past Hospitalizations (please include dates, or write N/A if not applicable) *

Current Medications and Dosages (separated by comma, or write N/A if not applicable)) *

Do you have Allergies? *

Yes No

Please list your allergies if applicable (separated by comma) *

Do you smoke cigarettes? *

Yes No Quit (please include year)

How many cigarettes do you smoke per day? (if applicable) *

What year did you quit? (if applicable) *

Do you use any other drugs? (i.e alcohol, marijuana) *

Yes No

If yes, please describe the frequency and amount used *

Please list any ongoing Medical Concerns (separated by comma, or write N/A if not applicable) *

Do you currently have a family doctor? *

Yes No Previous Doctor Retired

If yes, why are you looking for a new family doctor? *

Are you currently on Short Term or Long Term Disability? *

Short Term Long Term None

Do you have preexisting forms that need to be filled out by your doctor? *

Yes No

If yes, please describe *

By checking this box you understand that Dr. Imana does not prescribe any narcotics, chronic pain, or sedative medications *

I understand

Submit

Credit Valley Health Center
16-2555 Erin Centre Blvd
Mississauga ON, L5M 5H1
Phone: 905-828-0270
Fax: 905-828-0277