Family name: First name: Health card number: Birthdate: Sex: Male
Transcription
Family name: First name: Health card number: Birthdate: Sex: Male
IDENTIFICATION FORM FOR PEOPLE WITHOUT A FAMILY DOCTOR (COMPLETE ALL SECTIONS AND BRING THE FORM TO THE RECEPTION OF THE HOSPITAL) Family name: First name: Health card number: Birthdate: Sex: Male Address: Postal code: G4T_____ Female File number: ______________ Phone numbers where you can be reach easily Home: Cellular: Work: Other: To change doctors Reason for the change: Current doctor: Health questions Do you have health problems? Yes No If so, which ones? Presently, do you receive services form the CSSS des Îles? Yes No If so, which ones? _____________________________________________________ Do you take medication? Yes No How many kinds per day? ____________ Pharmacy: _____________________ Did you use services at the emergency in the last year? Yes No How many times? 1 -3 times 4-7 times 8 times and more Were you hospitalized in the last 2 years? Yes No If so, why? ______________________________________________ Did you have surgery in the last 2 years? Yes No If so, which? ______________________________________________________ I agree that the nurse consults my file when needed. I agree that my pharmacy forwards my pharmaceutical profile to the nurse at the access counter. Signature: ___________________________________Date :________________ ***Bring this form to the reception of the hospital. CSSS des Îles - Identification des personnes sans médecin de famille - Janvier 2014