CREDIT VALLEY HEALTH CENTER
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Dr. Mohammed Imana New Patient Intake
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Indicates required field
Name
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First
Last
Phone Number
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Email
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Date of Birth (dd/mm/yyyy)
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Parent/Guardian Name (if applicable)
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Health Card Number
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Version Code
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Gender (as it appears on your driver's licence)
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Male
Female
Other
Existing Medical Conditions (write N/A if not applicable)
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Past Surgeries or Procedures (please include dates, or write N/A if not applicable)
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Past Hospitalizations (please include dates, or write N/A if not applicable)
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Current Medications and Dosages (separated by comma, or write N/A if not applicable))
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Do you have Allergies?
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Yes
No
Please list your allergies if applicable (separated by comma)
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Do you smoke cigarettes?
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Yes
No
Quit (please include year)
How many cigarettes do you smoke per day? (if applicable)
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What year did you quit? (if applicable)
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Do you use any other drugs? (i.e alcohol, marijuana)
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Yes
No
If yes, please describe the frequency and amount used
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Please list any ongoing Medical Concerns (separated by comma, or write N/A if not applicable)
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Do you currently have a family doctor?
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Yes
No
Previous Doctor Retired
If yes, why are you looking for a new family doctor?
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Are you currently on Short Term or Long Term Disability?
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Short Term
Long Term
None
Do you have preexisting forms that need to be filled out by your doctor?
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Yes
No
If yes, please describe
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By checking this box you understand that Dr. Imana does not prescribe any narcotics, chronic pain, or sedative medications
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I understand
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Request Appointment
FHO After Hours
REGISTER
Psychotherapy
Book With Hazel
Speak to a Receptionist
RX RENEWAL
Home