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Essex County Nurse Practitioner-Led Clinic
Become A Patient
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Essex County Nurse Practitioner-Led Clinic
Become A Patient

Child Intake Form

(Newborn to 15 years old)

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    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

    Gender:
    Parents/Guardians:
    Who lives in the household? (check off all that apply)

    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

    Birth History

    This child is:
    Was the pregnancy full term?
    Were there any complications with the pregnancy or delivery?

    Growth and Development

    Medical History

    Has your child had any of the following conditions?

    Serious medical illness
    Asthma/wheezing/breathing problems
    Hospitalization and/or surgery
    Broken bones/injuries
    Behavioral problems
    Depression or anxiety
    Other?
    Do you have an extended drug plan? (eg Greenshield, Desjardins, Sunlife) YesNo

    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
    Bleeding/clotting disorder
    Genetic disorder
    Asthma/COPD

    Diet and Exercise

    Is your child physically active?
    How do you rate your child's diet?
    Is your child a picky eater?
    Does the child use any of the following? (check all that apply)
    Is the child exposed to second hand smoke in the home?

    Immunizations

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

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    • 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