Patient Intake Form

Patient Information

Full Name*

First Name Last Name

Preffered name (if different from above):

Pronoun

This will help us better understand how to address you (e.g.: She lives in Vancouver).

Please Specify:*

Primary Phone*

Email*

Enter Email Confirm Email

Date of Birth*

Personal Health/Care Card Number*

Emergency/Support Person Contact Information

Emergency Contact information*

Full Name Relationship

Primary Phone*

Personal Health History

Please check any current chronic conditions (in addition to cancer)*

heart disease

history of stroke

chronic obstructive pulmonary disease (COPD)

irregular heart rhythm

high blood pressure

kidney disease

none of the above

What is your typical blood pressure reading?

Do you have any cancer in your bones or have you been diagnosed with multiple myeloma?*

Yes

Please briefly describe any significant personal health history (e.g.: heart disease, osteoporosis, anxiety, etc.)

List your current medications, including supplements and herbal remedies

Medication name

Dosage

Reason used

Please click on the "+" button to the right of "Reason Used" field to add medications.

Please describe any substance intake and approximate frequency (e.g.: alcohol, tobacco, cannabis, etc.)

Have you recently had any significant fluctuations in weight and/or appetite? If yes, please describe:

Is there anything else you would like us to know?

Cancer Care Information

Cancer Diagnosis or Genetic Risk*

Stage (if known)

Date of Diagnosis:

Are you currently receiving cancer treatment?*

Yes

Where do/did you go for your cancer care? (e.g. BC Cancer in Victoria, Lions Gate Hospital, etc.):*

Please briefly describe any past or present cancer treatments and include approximate dates (e.g.: chemotherapy, radiation, surgery):

Do you have any cancer metastases ('mets' or spread of cancer)? If yes, please indicate where:

Individual Appointments

Complete as applicable.

What are you hoping for from your appointment with a Registered Dietitian?

What are you hoping for from your appointment with a Clinical Counsellor?

What are you hoping for from your appointment with an Exercise Therapist?

What are you hoping for from your appointment with a Supportive Care Physician?

Consent

Patients of InspireHealth requesting services have the right to Informed Consent; that is, your full and active participation in decisions which affect you and your freedom of choice based on the information shared. InspireHealth respects your right to ongoing informed consent at the outset of the therapeutic relationship and throughout your care. You have the right to withdraw consent at any time and terminate services. When it comes to the direction and goals of your therapy, you are the primary decision maker. You have the right to accept or reject any task, exercise, or practice suggested by your clinician, and to be informed of the risks, benefits, rationale, alternatives, and interpretations of all suggested interventions.

Hidden

Consent

2. LIMITS OF CONFIDENTIALITY

I acknowledge that I have read and understand InspireHealth's limits of confidentiality and consent to receive care from InspireHealth's clinical team.

Confidentiality is an essential part of the InspireHealth healing environment; your privacy is important to us. Your healthcare information belongs to you and is held in confidence by InspireHealth except in the case of the following circumstances:

1. If the information is required by law to be disclosed (e.g., child or vulnerable person in need of protection, court order, subpoenaed).
2. If staff believe there may be a significant risk of harm to you or others.
3. When informed and voluntary consent is provided by you to release information.

PATIENT RECORDS
Summarized information from appointments with clinicians will be charted in a secure electronic medical records system, which is encrypted and only accessible by InspireHealth clinical staff. Family members and support people will have a separate secure record in our system. Any paper documents will be kept in a locked and secure location. Emails may be used with your permission to provide details on resources you require. Please note that email content may become part of your InspireHealth chart.

GROUP CONFIDENTIALITY
When participating in a group setting, the InspireHealth clinician assures that they are connecting from a secure and private setting to hold the groups. Confidentiality for groups may be limited on the end of the group participants. To ensure confidentiality of the group, we ask all participants to connect from a secure and confidential space where conversation cannot be overheard by others. However, the clinician cannot assure the environment of the other group participants and therefore it is each participant’s responsibility to assure they are in a private and secure setting for their group experience. InspireHealth can therefore not take responsibility for the confidentiality being upheld by other group participants.

E-Signature*

First Name Last Name

Date*

Please note: