New Patient Form - Dr. C Lyddell

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City Province Postal Code

Phone*

Email

Gender*

Why are you seeing the Doctor today?

What is your marital status?

How many children do you have?

What is your Occupation?

Are you on Disability?

Yes
No

What is your Drug Plan?

Private Insurance
Over 65 Government
Blue Cross
Other

Details

Pharmacy

Name

Address

Street Address City Province Postal Code

Phone

Fax

Family Doctor

Name

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone

Past Medical History

1. Do you have or have you had any problems relating to your…?

Do you have or have you had any of the following illnesses?

Have you ever had a Stomach Ulcer or Bleeding?

Yes
No

What year did you have this?

How was it diagnosed?

Scope
Barium X-ray
Don’t Know

Have you ever had any surgeries/operations?

Yes
No

Please List

Please list any prescription or non-prescription MEDICATIONS you are taking now

Medication Name	Dose / Amount	How Often

What NSAIDs have you tried?

Do you have any ALLERGIES to Medications?

Yes
No

Please list the medication and describe what happens

Do you SMOKE cigarettes?

Never
Used to, but quit
Yes, still do

Number of years smoked

Number of packs smoked per day

Do you drink Alcohol?

Yes
Never

Number of drinks per week

Do any of your immediate family or distant family relatives have any of the following?

Please choose option number corresponding with the following diagram to show where you have had pain over the past month.

Comments

This field is for validation purposes and should be left unchanged.