New Patient Intake Questionnaire Step 1 of 3 33% Welcome to Murrayville Family Practice Group – Important Information(Required)Murrayville Family Practice Group is an inter-professional team-based Longitudinal Family Practice comprised of family physicians (FPs), family nurse practitioners (NPs), nurses (RNs), clinical pharmacist (RPh), and medical office assistants (MOAs). We work as one family practice with two locations: Murrayville and Willoughby. This means your primary care provider (PCP) may see you at either location depending on where they are working that day. Our FPs and NPs each have their own patient panel that they are responsible for, however, on occasion you may be seen with another member of our clinical team which includes Registered Nurses or our Clinical Pharmacist that are dedicated to providing our patients with comprehensive care. We provide care across the age continuum for everyone’s unique needs, from infant and child development and immunization to supporting frail and medically complex adults. We will work with you to develop a plan for your preventative health needs, including age-appropriate screening. We endeavor to provide care on a time appropriate basis. This includes care for unscheduled or unanticipated health problems. For patients already registered with our family practice who have an illness or injury that requires immediate attention, they can call the office for Urgent Care Monday – Friday between 8:00 AM – 8:50 AM. If you are a patient of Murrayville Family Practice Group and you have an urgent medical issue after hours that cannot wait until the office reopens, please call the office and listen carefully to the instructions on our phone system. Please be aware that this service is provided through HealthLinkBC and the After Hours Care team is not part of our practice. We encourage you to access care at our office whenever possible and avoid the use of walk-in-clinics. If you must use one, insist they forward copies of the visit and any investigations to our office. Not all clinics automatically do so. Our office is uniquely funded by the Ministry of Health to provide for the primary care needs for you and your family and as such, visits to walk-in-clinics create an outflow. Medication plays a crucial role in recovery from illness and in staying well, and we believe that you, the patient, have a role to play in adherence to medication regimens. This is why we typically will provide a year’s renewal of medicine (exceptions include narcotics, hypnotics, anxiolytics and certain other high-risk medicines). Certain intervals for lab work or office visits will be communicated as appropriate. We provide a patient portal with online access (Accession) so that you can refill your prescriptions, review test results, and book appointments. Please note: ONLINE BOOKING IS ONLY FOR PHONE APPTOINTMENTS AT THIS TIME. To sign up for accession, please go to https://murrayvillefamilypractice.ca/accession-request/ Prescriptions can also be renewed directly through your pharmacy. Please ask them to fax your refill request to our office. These will be reviewed and generally dealt with within 3-4 business days. In certain situations, you will be requested to attend a follow-up appointment in the office before the prescription refill is completed. Note that our office does have a 24-hour Cancellation Policy. In the event we are not notified, charges may apply. Our appointment cancellation line can be accessed 24/7 at 604-533-1140 (press 2). I have read and understand the information above, including how care is provided, clinic policies, and available services.Consent to Access PharmaNet PharmaNet is the secure network created to link community pharmacies and MDs and NPs throughout the province. Given the incredibly complex nature of medicine and the reality that most people have more than one health care provider prescribing for them, we as your health care provider must be able to access your current medication profile in order to protect you from potentially dangerous medication interactions and duplications. Only authorized staff have access to your health records including your medication profile.Consent(Required) I have read the above statement and give consent to Murrayville Family Practice Group to access PharmaNet Consent for the use of AI Scribe Technology At Murrayville Family Practice Group, we use AI-powered scribe technology to assist with medical documentation. This technology helps our providers focus on patient care while ensuring accurate and timely records. AI-generated notes are always reviewed and verified by a healthcare professional before becoming part of your medical record. If you have any questions, please speak with your healthcare provider. Please indicate your preference regarding the use of AI scribe technology during your appointments: Consent(Required) I consent to the use of AI scribe technology during my appointments. I do not consent to the use of AI scribe technology during my appointments. Practitioner Name:(Required) Enter practitioner nameEmail Date:(Required) Enter date password emailedHiddenEntered by: Enter initials of MOAThe purpose of this questionnaire is to ensure that your electronic medical record contains complete and up to date information so we can provide you with optimal comprehensive care. All information provided here will be kept strictly confidential.Name(Required) First Last Date of Birth(Required) DD dash MM dash YYYY Age(Required)Personal Health Number (PHN)(Required)Gender(Required) Male Female Non-binary HiddenDate of Birth Untitled Address(Required) Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Home phone (enter mobile/cell if no home phone)(Required)Cell phoneWork phoneEmail (By entering your email you agree to receive IN-OFFICE appointment reminders and other non-urgent communications by email)(Required) When appropriate, I agree to be contacted by: When appropriate, I agree to be contacted by SMS Text: The clinic may occasionally contact me by text message for non-urgent communication (optional) Alternate contact(Required) First Last Relationship(Required) Home phone (enter mobile/cell if no home phone)(Required)Cell phoneWork phonePrevious family doctor Referred to our clinic by(Required) Pharmacy of choice (please specify name and location)(Required) Which Lifelabs or hospital do you go to for blood work?(Required) SOCIAL HISTORYOccupation(Required) Employer Marital status(Required) Common law Divorced Married Never married Separated Widowed Religion # of ChildrenNames (age) Do you have a history of drug or alcohol abuse?(Required) Yes No Do you use recreational drugs?(Required) Yes No If yes, how often? Do you drink alcohol?(Required) Yes No If yes, how many drinks per week? Do you smoke or vape?(Required) Yes No How many cigarettes per day? Have you ever smoked?(Required) Yes No If yes, when did you quit? Please complete the questionnaire and click the SUBMIT button on the bottom of the page. MEDICAL HISTORY Have you ever suffered from any of the following health conditions?:Diabetes(Required) Yes No Please provide details: Heart Disease(Required) Yes No Please provide details: High blood pressure (Hypertension)(Required) Yes No Please provide details: Stroke(Required) Yes No Please provide details: Asthma(Required) Yes No Please provide details: COPD or other respiratory issues(Required) Yes No Please provide details: Food or seasonal allergies(Required) Yes No Please provide details: Gallstones(Required) Yes No Please provide details: Arthritis or joint pain(Required) Yes No Please provide details: Kidney or urinary issues(Required) Yes No Please provide details: Liver disease(Required) Yes No Please provide details: Sleep issues (apnea, snoring, insomnia)(Required) Yes No Please provide details: Stomach ulcer(Required) Yes No Please provide details: Heartburn or reflux (GERD)(Required) Yes No Please provide details: Neurological issues(Required) Yes No Please provide details: Anemia(Required) Yes No Please provide details: Blood clots(Required) Yes No Please provide details: Thyroid(Required) Yes No Please provide details: Cancer(Required) Yes No Please provide details: Anxiety(Required) Yes No Please provide details: Depression(Required) Yes No Please provide details: Other psychiatric illness(Required) Yes No Please provide details: Emergency room visit in past year(Required) Yes No Please provide details: Hospital admission in past year(Required) Yes No Please provide details: List any significant medical problems that have not been mentioned above:List any surgeries you have had and the year they occurred:List any diagnostic imaging (e.g. X-rays, MRI, CT, Ultrasound) and they year they occurred:PREVENTION AND WELLNESSHow would you rate your diet? Excellent Good Poor How would you rate activity level? Excellent Good Poor What do you do for exercise? What are your personal health goals? Please list any health screening tests or recommended immunizations you have received:Childhood immunizations up to date(Required) Yes No Annual flu shot(Required) Yes No Annual COVID-19 shot(Required) Yes No FIT stool test for colon cancer screening (every 2 years)(Required) Yes No Approximate date: Colonoscopy (every 10 years)(Required) Yes No Approximate date: Shingles vaccine(Required) Yes No Approximate date: Pneumonia vaccine(Required) Yes No Approximate date: Tetanus shot (every 10 years)(Required) Yes No Approximate date: Last PAP test (every 3 years)(Required) Yes No Approximate date: Last mammogram (every 2-3 years)(Required) Yes No Approximate date: FAMILY MEDICAL HISTORY Please indicate if any family members have significant health problems: Please include diabetes, heart disease, stroke, and cancer (specify what type)Were you adopted?(Required) Yes No Biological Parent 1 (maternal line)(Required) Alive Deceased Health history: Biological Parent 2 (paternal line)(Required) Alive Deceased Health history: Maternal Grandmother Alive Deceased Health history: Maternal Grandfather Alive Deceased Health history: Paternal Grandmother Alive Deceased Health history: Paternal Grandfather Alive Deceased Health history: Other relatives?: MEDICATIONS List your prescription medications (or attach a list), the strengths, and how you take them:List your non-prescription medications (over the counters, vitamins, herbals, etc.):List details of allergies or side effects to medications:(Required)
