Skip to content
Essex County Nurse Practitioner-Led Clinic
Become A Patient
  • About UsExpand
    • About ECNPLC & Nurse Practitioners
    • Mission, Vision & Values
    • Our Team
    • Board of Directors
    • Employment Opportunities
  • Services
  • Patient InformationExpand
    • Health & Wellness News
    • Become A Patient
    • Newsletter Signup
  • ProgramsExpand
    • Calendar
    • Essex Community Calendar
    • Windsor Community Calendar
    • Amherstburg Community Calendar
  • Resources
  • 3 Locations
Essex County Nurse Practitioner-Led Clinic
Become A Patient

Adult Intake Form

(16 Years and Older)

    1
    2
    3
    4
    5
    6
    7
    8
    9

     

    Thank you for your interest in becoming a client at Essex Nurse Practitioner Led Clinic. The ECNPLC collects, uses and discloses personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). The priority of the ECNPLC is to provide primary health care services to residents who live in Essex and surrounding communities who do not have a primary care provider. Please answer the following questions to the best of your knowledge.

    Preferred Location

    Personal Data

    Phone Numbers:
    Do you consent to receiving email communication? This form of communication will not include any personal health information and is strictly one-way. You will not be able to email us. YesNo

    Medical Information

    Medical History

    Check off all that apply to you

     

    Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNo

    Social History

    Employment Status: Full timePart timeSelf-employedUnemployedRetired
    Highest Education: No formal educationGrade schoolHigh schoolCollege/University
    Marital status: MarriedCommon-lawDivorcedSingleOther

    Risk Factors

    Tobacco Use

    Do you smoke or use tobacco?
    If yes, are you a previous smoker that quit?

    Alcohol Use

    Do you drink alcohol?

    Drug Use

    Have you ever used drugs?
    Do you use recreational drugs?
    Have you ever used needles to inject drugs?

    Diet

    How do you rate your diet?
    Do you eat or drink four servings of dairy or soy, or take calcium supplements daily?
    Do you eat all four food groups?
    How much caffeine do you consume?
    How many cups/cans per day?
    Are you satisfied with your weight?

    Exercise

    Do you exercise regularly?

    Sexual Activity

    Are you sexually active?
    Current sex partner(s) Birth Control Method
    Have you ever had any sexually transmitted infections/diseases (STDs)?

    Family History

    Please indicate if any blood relatives have suffered any of the following conditions. If yes, please indicate which family members (e.g. Parent, sibling, grandparent, and, uncle, etc.) had the condition.

    Alcoholism/Drug use?
    High cholesterol?
    High blood pressure?
    Stroke?
    Mental health problems?
    Diabetes?

    Cancer

    Breast cancer
    Lung cancer?
    Prostate cancer?
    Colon cancer?
    Uterine/ovarian cancer
    Have you had any previous hospitalizations, surgeries or injuries?

    I am:

    Female Medical History

    Are you currently pregnant? Describe your menstrual cycle:

    Pregnancies

    Have you ever been pregnant in the past?
    Have you had any abortions?

    Male Medical History

    Please indicate if you experience any of the following:

    Immunizations

    Please list the date of your last immunization for the following or indicate NA if you have not had one:

    ECNPLC is a member of the Windsor-Essex Ontario Health Team

    Follow Us!

    • Facebook
    • Instagram
    • YouTube

    Newsletter Signup

    SIGN UP

    Staff & Member Portal

    LOGIN

    © 2023 Essex County Nurse Practitioner-Led Clinic · Website by Oliver Marketing · Login

    • About Us
      • About ECNPLC & Nurse Practitioners
      • Mission, Vision & Values
      • Our Team
      • Board of Directors
      • Employment Opportunities
    • Services
    • Patient Information
      • Health & Wellness News
      • Become A Patient
      • Newsletter Signup
    • Programs
      • Calendar
      • Essex Community Calendar
      • Windsor Community Calendar
      • Amherstburg Community Calendar
    • Resources
    • 3 Locations