New Patient Intake Form | Dr. Chuks Nwulia Family Practice

Patient Information

Please provide your personal and contact details. Fields marked * are required.

Title

Date of Birth *

First Name *

Last Name *

Preferred Name (if different)

Ontario Health Card

OHIP Number

Version Code

Expiry Date

Home Address

Street Address *

City *

Postal Code *

Province

Contact Information

Home Phone

Cell Phone *

Email Address *

Preferred Contact Method

Preferred Language

Emergency Contact

Full Name *

Relationship *

Emergency Contact Phone *

Demographics & Lifestyle

This information helps us provide personalized, appropriate care. All responses are confidential.

Gender Identity

Biological Sex *

Used to determine relevant health screening sections.

Marital / Relationship Status

Occupation

Do you smoke or have you ever smoked? *

Yes, current smoker Former smoker Never smoked

Smoking Details

Type

Amount per day

How long have you smoked?

Former Smoker Details

Year you quit

Total years smoked

Do you consume alcohol? *

Yes No

Alcohol Use Details

How often?

Type of drink (if known)

Do you exercise regularly?

Yes No Sometimes

Diet restrictions or preferences

Past Medical & Surgical History

Please indicate any known medical conditions, past surgeries, and current medications. This information is kept strictly confidential.

Other conditions or additional details

Previous surgeries or hospitalizations

Are you currently taking any medications, including vitamins or supplements? *

Yes No

Current Medications

Please list all medications with dose and reason

Do you have or have you previously had a family doctor? *

Yes, I currently have one I had one previously No, I have not had one

Previous / Current Doctor Details

Doctor's name

Clinic or practice name

Reason for seeking a new family doctor

Any recent test results or specialist reports we should be aware of?

Female Health

This section covers reproductive and women's health history. All information is confidential and used only for medical care planning.

Date of last Pap smear

Leave blank if you have never had one or are unsure.

Date of last mammogram (if applicable)

Menstrual cycle status

Regular Irregular None (menopause) None (other reason)

Any menstrual concerns?

Number of pregnancies

Number of live births

Additional pregnancy history notes

Current contraception method

Are you currently pregnant or in menopause?

Menopause / HRT Information

Are you currently using hormone replacement therapy (HRT)?

Yes No Previously used

HRT details (type, duration)

Any breast health concerns?

Yes No

Please describe

Male Health

This section covers men's health history. All information is confidential and used only for medical care planning.

Do you have any prostate concerns or lower urinary tract symptoms?

Yes No

Please describe your symptoms

Date of last PSA test (if known)

PSA screening is typically discussed for men 50 and older, or earlier with risk factors.

Any urinary symptoms not already mentioned?

Yes No

Please describe

Any testicular concerns?

Yes No

Have you experienced erectile dysfunction?

Yes No Prefer not to say

Any concerns about testosterone levels?

Yes No

Immunisation

Please provide your vaccination history to the best of your knowledge. Bring your immunisation record to your first appointment if available.

Influenza (flu) vaccine — up to date?

Yes No Unsure

Last flu vaccine date (if known)

COVID-19 — vaccinated?

Yes No Partially

Number of COVID-19 doses

Tetanus / dTap — up to date?

Yes No Unsure

Last tetanus date (if known)

HPV vaccine?

Yes No Unsure / N/A

Shingles vaccine?

Yes No Unsure / N/A

Pneumococcal vaccine (for pneumonia, typically 65+)?

Yes No Unsure / N/A

Have you received vaccines outside of Canada?

Yes No

Please describe (country, approximate dates, vaccines received)

Allergies

List all known allergies including the reaction experienced. If you have no known allergies, check the box at the bottom.

No known allergies — I have no known drug, food, or environmental allergies

Drug / Medication Allergies

Food Allergies

Environmental Allergies

Other Allergies (latex, insect stings, etc.)

Family History

Please indicate any significant health conditions in your immediate family. This helps identify hereditary risks and guides preventive care.

For each condition, note which family member(s) are/were affected (e.g. Father, Mother, Sibling, Grandparent).

Heart Disease

High Blood Pressure

Diabetes (Type 1 or 2)

Cancer

Stroke

Mental Health Conditions

Thyroid Conditions

Kidney Disease

Other Hereditary Conditions

Additional Notes

Share any other information that would help Dr. Nwulia understand your health needs and priorities.

Reason for seeking a new family doctor

Is there anything specific you would like to prioritize at your first appointment?

Any other health concerns or information you would like to share

How did you hear about this clinic?

Request for Patient Enrollment

Patient Information

Demographics & Lifestyle

Past Medical & Surgical History

Female Health

Male Health

Immunisation

Allergies

Family History

Additional Notes

Thank You