Female Registration Date Date Format: MM slash DD slash YYYY SURNAME:FIRST NAME:DATE OF BIRTH Date Format: MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country HOME TELBUS. TELMOBILEEmail OHIP NOVERSION CODEMARITAL STATUSCHILDRENOCCUPATIONHOW DID YOU HEAR ABOUT THIS CLINIC?NAME OF CONTACT IN CASE OF EMERGENCYTEL. NUMBERSMOKER ? YES NO ALCOHOL CONSUMPTIONLIST OF MEDICATIONS (DOSAGES/FREQUENCY/FOR WHAT REASONDRUG ALLERGIES FAMILY HEALTH HISTORY (Note cause of death if deceased): MOTHERFATHERSISTERSOTHER FEMALE RELATIVESOTHER RELEVANT FAMILY HISTORYPAST MEDICAL CONDITIONSPAST SURGERIESPLEASE LIST YOUR MAIN CONCERNS THAT BROUGHT YOU TO THE CLINIC: PLEASE SELECT BELOW IF YOU ARE CURRENTLY EXPERIENCING ANY OF THE FOLLOWING SYMPTOMS GENERAL Fatigue Hot flashes Fainting Loss of Appetite Night sweats Fever Weight loss Heat intolerance Chills Weight gain Cold intolerance Easy bruising Difficulty sleeping Bloating Decreased sex drive SKIN Dry skin Facial hair Acne Hair loss Rashes/hives HEART AND CIRCULATION Palpitations Leg pain while walking Swelling of the ankles Chest pain /tightness Varicose veins DIGESTION Difficulty swallowing Abdominal pain Gas Heartburn Constipation Regular laxative use Nausea/ Vomiting Loose bowel movements Bloody/ Black stools URINATION Frequent urination Change in appearance of urine Bladder infections Painful urination Problems holding urine Getting up at night to urinateIf so, how many timesSKELETAL SYSTEM Pain or stiffness of joints History of fractures Back pain Swelling of joints Foot problems Deformities NERVOUS SYSTEM Forgetfulness Abnormal sensations Spells of any kind Nervousness/Anxiety Loss of balance Dizziness Depression Difficulty walking Muscle weakness Foggy thinking Clumsiness Tremors MENSTRUAL/GYNECOLOGICAL HISTORY Regular cycles Painful Breasts/Lumpy breasts Irregular cycles Infertility Painful menstruation Very heavy periods Abnormal vaginal discharge Vaginal dryness Bleeding between periods Painful intercourse Length of periods DaysLength of cycle DaysAge of 1st periodNumber of pregnanciesNumber of MiscarriagesAre you using any method of contraception?What method are you using/used in the past?Date of last periodDate of last pap smearDate of last mammogram/breast ultrasoundName of Family DoctorDate of last physicalNameThis field is for validation purposes and should be left unchanged.