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Huronianplc.ca

Huronia Nurse Practitioner-Led Clinic
3331 Line 4 North, RR1
Shanty Bay, ON L0L 2L0
Ph) 705-835-7545

Fax) 705-835-6424

PLEASE RETURN FORMS VIA: FAX, MAIL OR DROP OFF TO CLINIC

CLIENT APPLICATION FORM-CHILD/ADOLESCENT
The Huronia Nurse Practitioner-Led Clinic collects, uses and discloses your personal information in compliance with the guidelines of the Personal Health Information Policy Act (PHIPA). The information collected in this form will be used for the purposes of program and service planning. Your personal information will not be used for any other reason without your consent. Our staff are required to keep personal information confidential. In order to provide services that meet your needs and the abilities of the providers in the clinic, information provided must be truthful, accurate and as complete as possible. In which township do you reside? _________________________________________ Have you registered with Health Care Connect? Do you have a family doctor or nurse practitioner? Yes □ No □ Name and address/phone number of your family doctor or nurse practitioner: ______________________________________________________________________ When was the last time you saw your doctor/nurse practitioner? __________________ DEMOGRAPHIC INFORMATION
Surname (as appears on health card): _____________________________________ Other surname: _______________________________________________________ Given Names: _________________________________ Birth Date (year/month/day)______________________ Health Card Number: ________________________ Version code: _____ or Status Card Number: ______________________ The following questions are asked to collect information pertaining to the determinants of health: Gender: Male □ Female □ First Language: ___________________ Ethnicity: Caucasian □ Asian □ First Nation □ African-Canadian □ Metis □ South Asian □ Other □ Parent(s) or Guardian: ______________________________________________________________ Relationship: ___________________________________________________ Address: _____________________________________________________ ______________________________________________________________ ______________________________________________________________ Is there a custodial parent? Indicate which parent has custody: Mother? □ Father? □ Mother’s Home Phone: ( ) - Work Phone: ( )______-__________ Mobile Phone: ( ) -______ ________ Father’s Home Phone: ( ) - Work Phone: ( ) -__________ Mobile Phone: ( ) -______________ What are the names and ages of your child’s siblings? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ HEALTH INFORMATION
When did you last see an eye doctor? _______________________
When did you last see a dentist? ____________________________
Exercise/Activity:
Type?

How much time per day?
How many days per
week?


How much leisure time do you spend watching TV, using video games on the
internet/computer per day? ____ hours
Vaccination History: Please provide a copy of vaccination record

Childhood Illnesses:

Chicken Pox: Yes □ No □ Measles: Yes □ No □ Mumps: Yes □ No □ Rubella: Yes □ No □ Scarlet Fever: Yes □ No □ Has your child ever tested positive for Tuberculosis? Yes □ No □ Is there a diagnosed learning disability? Yes □ No □ Are they any hearing, vision or speech/language problems? Yes □ No □ Does your child have any disabilities? Yes □ No □ Please expand: ________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________ Does your child attend daycare? Yes □ No □ What level of schooling does your child attend? Pre-school □ Primary School □ Home School □ High School □ Do you drive a motor vehicle? Yes □ No □ Do you smoke or use tobacco (cigarettes, cigars, chewing tobacco? Yes □ No □ How many per day? _______________________ How many drinks per week? ________________ If birth control is used, what method of birth control is being used at this time? ________________________________________________________________
Pregnancy and Delivery History:

Any health problems during pregnancy with mom or baby?_______________________
Preterm or fullterm pregnancy? _____________________________________
Type of Birth-vaginal or caesarean? _________________________________
Any complications during your birth?
______________________________________________________________________
______________________________________________________________________
Any problems with the baby after delivery and for the first weeks of birth?
______________________________________________________________________
______________________________________________________________________
Medical Illnesses or Injuries:
Type of Illness, Disease or Condition

When was this problem diagnosed?

Operations:
Type of Operation

What year?
Location
Orillia Soldier’s Memorial Hospital/RVH
Does your child see any Specialists?
Name of Specialist

Address or phone
Reason that you see this
number of Specialist
specialist?

Does your child see any other health professionals?
Type of health professional

Location or phone
Reason that you see
this professional?

Medications:
Name of Medication, Dose, How often it

Reason for Taking Medication
is taken
E.g. Ventolin, 2 puffs, 4 times a day

Over the Counter Medications/Vitamins/Herbal or Alternative Therapies:
Name, Dose, How Often

Reason for Taking Therapy
Name of Pharmacy: ____________________________________________________________________ Pharmacy Location or Phone number: ____________________________________________________________________ Do you have a private drug benefits plan (e.g. Blue Cross, Great West Life): Yes □ No □ Do you have a publicly funded drug plan (Ontario Disability and Support Program)? Yes □ No □ Medication Allergies: ____________________________________________________________________________________________________________________________________________ Environmental Allergies: Food Allergies or Sensitivities: __________________________________________________________________________________________________________________________________________________________________________________________________________________ Latex Allergy? Yes □ No □ Briefly describe your child’s current health concerns: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ How soon do you require a visit to a practitioner? ______________________________________________________________________ Signature: _____________________________________ Date: _________________ Thank you for taking the time to complete this registration form. All personal health information will be kept confidential.

Source: http://www.huronianplc.ca/wp-content/uploads/2013/11/Client-Registration-Form-Child-Adolescent.pdf

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