Patient Intake Private – Allurion Balloon Program

New Patient Questionnaire

First Name

Middle Name

Last Name

Maiden Name

Date of Birth

Age

Gender

Height

Weight

Mailing Address

City

Province

Postal Code

Phone number / Home

Phone number / Mobile

Phone number / Work

Provincial Health Care Number

Issuing Province

Expiring date

Emergency Contact's Full Name

Relationship

Phone number

Preferred Pharmacy Name

Preferred Pharmacy Location

City

Medication List: (Include over the counter and supplements/vitamins)

If NONE

Check here if you don't take any medication

Allergies & Intolerances:

If NONE

Check here if you don't have any allergies or intolerances

Add details here:

Other:

Family History

Do you smoke, chew tobacco or vape

Yes No

If yes, how much? : ________________________________________________________

Do you drink alcohol?

Yes No

If yes, how much? : ________________________________________________________

How would you describe your level of exercise?

None Minimal Normal Heavy

Do you drink caffeine? (pop, coffee, etc.)

Yes No

If yes, how much per day? : ________________________________________________________

Do you use recreational drugs or have you in the past?

Yes No

If yes, how much/What Type? : ________________________________________________________

Are you employed, if yes, what is your job title?

What is your marital status?

Do you have any children, if yes, how many?

Comments

Working Hours

Serving You:
Globally Eastern Time
8:00am – 5:00pm Mon-Fri
9:00am – 3:00pm Sat
HEAD OFFICE
RAPID ACCESS MEDICAL Corp.
203, 97 – Centre St SW,

Langdon, AB T0J 1X2, Canada

(403) 936-5990 Office

(403) 936-5997 Fax

This website is owned and operated by Rapid Access Medical Corp®

We are an independent certified Allurion Provider.