Client Intake Form

Please complete all fields as accurately as possible before your first appointment. Your information is kept strictly confidential.

Fields marked * are required.

Personal Information

First name *

Last name *

Health card number *

Date of birth *

Contact number *

Email address *

Street address *

City *

Province *

Postal code *

Medications, Allergies & Medical History

Current medications

List all medications taken on a regular basis, including dose if known. Write "None" if not applicable.

Allergies

Include allergies to medications, foods, and environmental triggers. Write "None" if not applicable.

Past medical history

List any past or current diagnoses, surgeries, or hospitalizations. Write "None" if not applicable.

Health Screening

Please answer yes or no to each of the following questions. *

Do you have Type 1 diabetes and take insulin?

Yes No

Have you ever been diagnosed with pancreatitis?

Yes No

Have you ever been told you have medullary thyroid cancer?

Yes No

Are you peri-menopausal or post-menopausal?

Yes No

Are you currently taking birth control?

Yes No

Are you currently pregnant, or planning to become pregnant in the next 12 months?

Yes No

Are you currently breastfeeding?

Yes No

Current Measurements

Current weight *

Current height *

Appointment Preference

Would you prefer a virtual or in-person appointment? *

Virtual In-person Either works for me

JEMA Health

NP-led health and wellness clinic specializing in weight management. Stop the cycle of weight gain and achieve better health.