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Respirology
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1
Patient Full Name
*
This field is required.
Format: Last name, First name
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2
Health Card Number
Leave blank if you do not have a health card (i.e Out of country, refugee etc.)
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3
Cellphone Number
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Enter phone number WITHOUT any dashes or '1" in front of it. For example: 9058979228. Enter the SAME PHONE NUMBER that you have been receiving text messages from the clinic.
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4
Date Of Birth
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Enter in the following format: YYYY-MM-DD. For example: 2020-12-31 for December 31st, 2020
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5
Current Address Including postal code
Enter your address with your postal code. For example: Suite 110 - 21 Queensway West, Mississauga, ON L5B1B6
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6
Email
example@example.com
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7
Were you born and raised in Canada. If not which country were you born in and when did you move to Canada?
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8
Do you smoke? If yes how frequently and how much do you smoke? (Leave blank if not applicable)
Example: Smoke 3 times a day, 2 cigarettes each time
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9
Have you ever smoked? If so when did you quit smoking? (Leave blank if not applicable)
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10
Please list all previous and current occupation(s) (Leave blank if not applicable)
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11
Do you have environmental allergies (dust, pollen, etc), if yes please list them below
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12
Have you ever been diagnosed with tuberculosis(TB), if so were you treated, when were you treated and how long was your treatment?
Example: Diagnosed 3 years ago, was treated for 6 months in 2018
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13
Did you ever get a BCG/TB vaccine?
Yes
No
I don't know
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14
Have you ever been diagnosed with asthma or COPD?
YES
NO
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