Questionnaire Error Submitting Questionnaire ... Erase & Resubmit Questionnaire As a current patient of Summit Health, we have the medical questionnaire on file that was completed for your last visit. I confirm there has been no change to my health or medication since my previous visit to Summit Health. Confirm Fill In New Questionnaire Demographic Information First Name* First Name is a required field Last Name* Last Name is a required field Birthdate* Birthdate is a required field Health Card Number Country Canada USA Other Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon State* state is a required field. Email* Email is a required field Phone* Phone is a required field Preferred Language English French Street* Street is a required field City* City is a required field Zip Code* Zip Code is a required field. Postal Code* Postal Code is a required field. Medical Information Do you have or have you ever been told that you have a cardiovascular disease?* None High Blood Pressure Heart Failure Arrhythmia Angina Aneurysm Heart Attack Bypass/stents Stroke/TIA Pulmonary Embolism Claudication DVT/Blood Clot Other Other Have you experienced any of the following symptoms in the past year?* None A productive cough for more than 3 weeks Hemoptysis (coughing up blood) Unexplained weight loss Fever, Chills, or night sweats for no known reason Persistent shortness of breath Unexplained fatigue Have you ever had a positive TB skin test?* No Yes When was your positive TB skin test Have you ever been in close contact with anyone who was sick with TB?* No Yes When were you in contact with someone with TB Have you ever been vaccinated with BCG (Bacillus Calmette–Guérin)?* No Yes If yes, when were you vaccinated Why do you require a TB Skin Test? Do you have any allergies?* No Known Allergies Yes Seasonal Allergies Allergies Have you ever been told that you have a pulmonary condition/respiratory illness?* None COPD Sleep Apnea Emphysema Chronic Bronchitis Asthma Pulmonary Fibrosis Other Other Do you have a digestive condition/gastro-intestinal illness?* None Irritable Bowel Syndrome Crohn's disease Colitis Gastric Reflux Other Other Do you have a liver disease? Have you ever had a hepatitis infection?* None Hepatitis A Hepatitis B Hepatitis C Other Other Have you ever had kidney issues or have you been diagnosed with a kidney illness?* Yes No Please Specify Have you ever been diagnosed with cancer?* Yes No Please Specify Have you ever experienced or been diagnosed with a neurological disorder? * None Epilepsy Convulsions or Seizures Meningitis Cerebral Malaria Other Other Have you ever experience or been diagnosed with a psychiatric disorder?* None Depression Anxiety Bipolar Schizophrenia Burnout/Medical Leave of Absence Other Other Do you presently have any skin disorders?* None Psoriasis Eczema Other Other Are you presently or have you ever been immunosuppressed (impaired immune system)?* None Due to Medication Hereditary Conditions Splenectomy HIV AIDS Other Other Have you ever been diagnosed with diabetes?* Yes No Please Specify Do you have any chronic or acute conditions, disorders or illnesses that were not mentioned above?* Chronic illness a required field Maternity status None I am pregnant I am planning a pregnancy I am breastfeeding Do you take any regular medications? If yes, please include all prescription medications, puffers/inhalers, herbal supplements and over-the-counter medications?* Medications is a required field Have you received all of your childhood vaccines? Yes No In which province/country did you receive your childhood vaccines? Do you live or work in close contact with the following populations? None Babies/Children Elderly Someone With A Chronic Illness Have you ever had an adverse reaction to a vaccine? None Anaphylactic Shock Vasovagal Other Other Do you smoke cigarettes? Yes No Destination Information Please add all of the countries you will be visiting by searching below and clicking "add country to list" Country Country is a required field & must be selected from the list Cities Visited Cities visiting is a required field Days In Country Days in country is a required field Add Country To List Trip Information Departure Date departure date is a required field Purpose of Trip Visiting Family/Friends Pleasure Holiday Business Volunteer Work Academic Adoption Possible Activities Climbing/High Altitude Extreme Sports Farming Healthcare Jogging/Bicycling Other Other Travel Accommodations All-inclusive resort Family/Friends Hotel Camping Villa Hostel Apartment Other Other Emergency Contact Emergency Contact Name Emergency contact name is a required field Emergency Contact Number Emergency contact number is a required field Parent or legal guardian name, if applicable Pharmacy Information Please provide the information of your pharmacy so that we can send prescriptions directly to your pharmacy (Optional) Pharmacy Name Pharmacy name is a required field Pharmacy Fax Pharmacy fax is a required field I declare that all the information provided above is complete and accurate to the best of my knowledge. I understand that any false information could be detrimental to my health. I agree with the website privacy policy and the personal information policy of Summit Health I am aware that all vaccines and medications discussed during consultation are recommendations and are not requirements, unless otherwise specified on the Government of Canada Travel website (ex. Yellow Fever entry requirements). I understand that I am responsible for all pertinent information regarding my necessary travel documents and visa(s) requirements. I am aware that it is recommended that I remain in the clinic for 15 minutes post-vaccination. I understand that I am responsible for the proper handling of all medication and vaccines purchased for later consumption (Ex: Dukoral and Vivotif). I understand that these vaccines must be refridgerated between 2-8 degrees celcius at all times. I am aware that consultation fees and vaccination fees apply to all visits. I understand that the payment of these fees is due at the time of my appointment, and that all payments must be made by card (Credit Card or Interac). I agree to receive the results of my COVID-19 test by email. I confirm that the test results should be sent to the email address indicated above. Paladin Security I consent to Summit Health releasing my medical and immunization record directly to Paladin Security Group Ltd for the purposes of verifying my eligibility to work in a hospital setting as per The Public Hospitals Act, Ontario Hospital Association and Ontario Medical Association Guidelines. Add Your Immunization Record Please take a photo or upload a file with your existing immunization record to help make your appointment as efficient as possible. Please bring your immunization record with you to your appointment Submit Submitting Questionnaire ...
