Medical Questionnaire Please be sure enter your information below exactly as it is displayed on your passport. 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 Province Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Northwest Territories Nunavut Yukon Postal Code* Postal Code 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 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 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?* This is 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?* This 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 This is a required field Cities Visited This is a required field Days In Country This is a required field Add Country To List Trip Information Departure Date This 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 This is a required field Emergency Contact Number This is a required field Parent or legal guardian name, if applicable 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 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). Submit Submitting Questionnaire ...
