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First Name

Last Name

Gender

Male Female Other

Date Of Birth

Age

Blood Type

Email

Phone Number

Address

City

Province

Postal Code

Clinic ID

Do you have a regular family doctor?

Yes No

If Yes

Health Card Number

Background

Medical problems

Yes No

If Yes

Medications

Yes No

If Yes

Allergies

Yes No

If Yes

Smoker

Yes No

Do you have any of the below

Cough

Yes No

Fever 38 or Greater

Yes No

Shortness of breath or chest discomfort

Yes No

Runny Nose

Yes No

Vomiting

Yes No

Diarrhea

Yes No

Abdominal Pain

Yes No

Rash

Yes No

Eye Discharge

Yes No

Travel in last 14 days outside of Durham

Yes No

Contact with person diagnosed positive with COVID 19 or other communicable disease in last 14 days

Yes No

Have you been discharged from hospital in the last 14 days

Yes No

If you answered yes to any of the questions above please describe

Main reason for medical visit request today

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