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