Patient Intake Form

Thank you for providing this helpful information while waiting - it will allow me to know more about your background and save asking you so many questions

CONTACT INFORMATION

Full Name: Age:

What name do you prefer to be called?

Phone: Home Work Cell

Email:

Emergency contact: Relationship:

Contact's Phone:

MEDICAL TEAM

Family doctor / Nurse Practitioner: None

What is your main medical question for Dr. Moore?

Other specialists involved in your care?

Any upcoming surgery?

Prescription Insurance: None (I pay the full cost) NB Seniors (Blue Cross) NB Drug Plan Social services plan Native plan Private or Group plan:

Preferred Pharmacy:

RESIDENCE / EMPLOYMENT / RELATIONSHIPS

Does anyone live at home with you?

Education: Student Reading difficulties

Occupations: Current Past

Full-time Part-time Retired Disabled

HABITS AND ACTIVITIES

Nicotine/tobacco use? Never smoked Former smoker Current smoker

When did you quit?

After packs per day for years

Cigarettes Cigars Vape Chewing tobacco

How many packs per day? for years

Tried to quit but restarted times Interested in quitting Not ready to quit at this time

Alcohol use? None Some Past or current struggle with alcohol

drinks average per day per week

Marijuana or CBD oil use? None Recreational Medical

Other recreational drug use? No Yes

Cocaine Meth Other:

Coffees or other caffeinated drinks per day:

Height: Weight: Not sure

Do you get regular exercise? Not much Yes –

Any hobbies or leisure activities you wish to share?

ALLERGIES / SIDE EFFECTS

I have no allergies

List any medication allergies or side effects and the type of reaction you had:

Allergen	Reaction

MEDICAL CONDITIONS

Heart Disease Risk Factors

Heart Problems

Heart Attack (MI) Angina Coronary 'balloon' or 'stent' Coronary artery bypass surgery (CABG) Valve surgery Defibrillator (ICD) Pacemaker Atrial fibrillation Heart Failure

Other:

Any lung disease? No Yes

Asthma COPD Emphysema Pulmonary embolism (blood clot in lung)

Any gastro intestinal disease? No Yes

Heart burn Irritable bowel syndrome (IBS) Ulcerative colitis Crohn's disease Celiac disease

Other:

Any liver disease? No Yes

Fatty liver Cirrhosis Hepatitis C

Treated

Any mental health problems? No Yes

Any rheumatologic / arthritis / pain problems? No Yes

Any thyroid disorders? No Yes

Hypothyroidism (underactive) Hyperthyroidism (overactive)

Any cancer? No Yes

Breast cancer Prostate cancer Bowel cancer Lung cancer

Other:

OTHER CONDITIONS

List any other medical conditions not covered above:

Condition Details

PAST SURGERIES

List past surgeries:

Surgery Details	Year

FAMILY HISTORY

Adopted (list only info known re. biological relatives)

Please list close relatives and rough ages (or age at time of death). Especially list any history of heart disease, sudden death, diabetes, cholesterol, high BP, cancer.

Relation	Status	Age	Medical conditions / Cause of death