Medical Questionnaire Form
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3The information in this questionnaire is CONFIDENTIAL and enables our office to provide the highest level of care and service possible.
Please complete all forms as completely as possible. Thank you.
PATIENT CONTACT INFORMATION
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Mr
Mrs
Ms
Miss
Dr
First Name: _____________________________________________ Last Name: ___________________________________________
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Preferred Name: ________________________________________ Date of Birth: ______________ (DD/MM/YY)
Male
Female
Address: ____________________________________________________________________________ Apt/Unit #: ________________
City: _________________________________________ Province: ______________________________ Postal Code: ______________
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Home Phone: __________________________________
Marital Status:
Single
Married/Common Law
Other
Employer: ___________________________________________________ Position: _________________________________________
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May we contact you at your workplace?
Yes
No
Work Number: _______________________________________________
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May we contact you on your cell phone?
Yes
No
Cell Number: ________________________________________________
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May we contact you by email?
Yes
No
Email address: ______________________________________________________
In case of an emergency please notify: _________________________________________ Phone number: ________________________
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Best way to contact you?
Home
Work
Cell
Email Best time to contact you?
Morning
Afternoon
Evening
INSURANCE INFORMATION
Primary Insurance Company Information
Name of Insurance Policy Holder: ________________________________________________ Date of Birth: _____________ (DD/MM/YY)
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Insurance Policy Holder:
Self
Parent/Guardian
Other _________________________________________________________
Policy Holder Phone Number (if different from above): ____________________ Employer: _____________________________________
Insurance Company Name: ______________________________ Group Policy/Plan Number: _________ I.D./Certificate Number: ______
Secondary Insurance Company Information
Name of Insurance Policy Holder: ________________________________________________ Date of Birth: _____________ (DD/MM/YY)
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Insurance Policy Holder:
Self
Parent/Guardian
Other _________________________________________________________
Policy Holder Phone Number (if different from above): ____________________ Employer: _____________________________________
Insurance Company Name: ______________________________ Group Policy/Plan Number: _________ I.D./Certificate Number: ______
REFERRAL INFORMATION
How did you hear about us? (Check all that apply)
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Internet — Website/search engine source: ________________________________________________________________________
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Flyer — flyer description: _____________________________________________________________________________________
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Newspaper — newspaper name(s): _____________________________________________________________________________
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Word of Mouth — name of person: _____________________________________________________________________________
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Walked By
Other — please specify: ___________________________________________________________________
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Parent category: Life