First Visit Form

Only complete this form if this will be your first visit. All other patients need to use THIS FORM for review patients.

Fields marked with an asterisk (*) are required.

Click here to review practice policies

Part 1 - Personal Details

First Name *

Last Name *

Middle Initial

Date of Birth *

Day of Birth *

Month of Birth *

Year of Birth *

Email

Home Phone

Cell Phone

Address *

City *

Postal Code

Are you on disability?

Yes

No

Occupation

Relationship status

Part 2 - Medical Information

Medical History - please check any of the following specific conditions you have had in the past or still have. We will discuss these at your appointment.

Heart disease or angina

Lung disease e.g. asthma, COPD

Thyroid disease

Osteoporosis

Liver disease e.g. hepatitis

High blood pressure

Psoriasis

Diabetes

Crohn's or colitis

Blood clot (thrombosis)

Stomach ulcer

Kidney disease

Smoking and alcohol

Alcohol history

No, I do not drink alcohol

Yes, I drink alcohol

Smoking history

Never smoked

Used to smoke

I currently smoke

Drug allergies

Do you have any allergies to drugs?

Yes

No

Medications

Are you on any medications?

Yes

No

Previous surgeries

Have you had any surgeries?

Yes

No

Part 3 - Symptoms and function

Dressing and Grooming

Over the past week...

Were you able to dress yourself, including tying shoelaces and doing buttons?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Shampoo your hair?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Arising

Over the past week...

Were you able to stand up from an armless chair?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get in and out of bed?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Eating

Over the past week...

Were you able to cut your meat?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to lift a full cup or glass to your mouth?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to open a new milk carton?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Walking

Over the past week...

Were you able to walk outdoors on flat ground?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to climb up five steps?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Hygiene

Over the past week...

Were you able to wash and dry your entire body?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to take a tub bath?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get on and off the toilet?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Reach

Over the past week...

Were you able to reach and get a 5lb object (e.g. bag of sugar) from just above your head?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to bend down and pick up clothing from the floor?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Grip

Over the past week...

Were you able to open car doors?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to open jars which have been previously opened?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to turn faucets on and off?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Activities

Over the past week...

Were you able to run errands and shop?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to get in and out of a car?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Were you able to do chores such as vacuuming, yard work?

No difficulty

Mild difficulty

Moderate difficulty

Unable

Please check any aids or devices that you usually use for any of these activities

Cane

Walker

Crutches

Wheelchair

Devices used for dressing, e.g. button hook

Built-up or special utensils

Special or built-up chair

Other

Please check any categories for which you need help from another person.

Dressing and grooming

Eating

Arising

Walking

List aids and devices you usually use for any of these activities.

Raised toilet seat

Bathtub seat

Bathtub bar

Long handled appliance in bathroom

Long handled appliance for reach

Jar opener

Hygiene

Errands and chores

Gripping and opening things

Compared to 6 months ago, is your ability to manage aspects of daily life

Function is...

Better

Same

Worse

How long (in minutes) does your morning stiffness last from the time you wake up? (0 is no stiffness, 120 is 2+ Hours)

0

How do you rate your pain on a scale of 10 (in the last 7 days)? 0 is no pain, 10 is the worst pain you can imagine.

0

How do you rate your fatigue on a scale of 10 (in the last 7 days)? 0 is no fatigue, 10 is the worst fatigue you can imagine.

0

How active has your arthritis been in the LAST 24 HOURS? Zero is NOT active, 10 is the most active it could ever be.

0

Part 4 - Patient Agreement

I ,
confirm that I have read the patient information and practice policy handout or website information

I agree to take responsibility for my own health and be an active partner in my own healthcare

I agree to attend all appointments, treatment schedules and consultations as requested by my physician

I understand and agree to the policies of this practice, specifically:

	I will bring my health card and a list of my medication to every visit and I understand that I may not be seen without a valid health card.
	I understand that I will be asked to complete online patient forms before every visit.
	I am aware that there are fees associated with some uninsured services and I am responsible for paying these (e.g. sick note, disability forms, insurance forms and medical reports)
	I understand that it is NEVER acceptable to verbally or physically abuse any clinic staff and that such behaviour will lead to immediate termination of the physician-patient relationship.
	I understand and agree to the principles of this practice. If I am unable to follow these principles, I am aware I may be discharged from the practice.

Signed:

Send me a copy of this completed form