Dr. Jeff Moore MD FRCPC

506-447-4041 (ph.)
506-457-4758 (fax)

Admin Assistant: Paula.Mowatt@HorizonNB.ca

Internal Medicine
Cardiovascular Disease

1015 Regent St, Suite 302
Fredericton, N.B. E3B 6H5

Patient Intake Form

Thank you for providing this helpful information - it will allow me to know more about your background and save asking you so many questions at the time of the visit

Note that after submitting, this information will be sent directly to the office and not stored on the server. If you prefer a paper form, that is available at the office.

CONTACT INFORMATION

Full Name: Age:

What name do you prefer to be called?

Phone: Home Work Cell

Email:

It is very helpful if you would please include a photo of yourself for our EMR chart — this helps me to remember you for future visits especially if virtual

Photo will be sent to the office with your form. Uses your webcam on a computer or camera on a phone.

Emergency contact: Relationship:

Contact's Phone:

MEDICAL TEAM

Family doctor / Nurse Practitioner: None

What is your main medical question for Dr. Moore?

Other specialists involved in your care?

Any upcoming surgery?

Prescription Insurance: None (I pay the full cost) NB Seniors (Blue Cross) NB Drug Plan Social services plan Native plan Private or Group plan:

Preferred Pharmacy:

RESIDENCE / EMPLOYMENT / RELATIONSHIPS

Does anyone live at home with you?

Education: Student Reading difficulties

Occupations: Current Past

Full-time Part-time Retired Disabled

HABITS AND ACTIVITIES

Nicotine/tobacco use? Never smoked/vaped Former smoker/vaper Current smoker/vaper

When did you quit?

After packs per day for years

Cigarettes Cigars Vape Chewing tobacco

Interested in quitting Not ready to quit at this time

Alcohol use? None Some Past or current struggle with alcohol

drinks average per day per week

Marijuana or CBD oil use? None Recreational Medical

Frequency: Daily use Weekly use Occasional use

Other recreational drug use? No Yes

Cocaine Meth Other:

Coffees or other caffeinated drinks per day:

Height: foot inches

Fill in cm instead

Weight: Not sure

Do you get regular exercise? Not much Yes –

Any hobbies or leisure activities you wish to share?

ALLERGIES / SIDE EFFECTS

I have no allergies

List any medication allergies or side effects and the type of reaction you had:

Allergen	Reaction

MEDICAL CONDITIONS

Heart Disease Risk Factors

Heart Problems

Any lung disease? No Yes

Asthma COPD Emphysema Interstitial pulmonary fibrosis

Any gastro intestinal disease? No Yes

Heartburn Irritable bowel syndrome (IBS) Ulcerative colitis Crohn's disease Celiac disease

Other:

Any liver disease? No Yes

Fatty liver Cirrhosis Hepatitis C

Treated

Any mental health problems? No Yes

Any rheumatologic / arthritis / pain problems? No Yes

Any thyroid disorders? No Yes

Hypothyroidism (underactive) Hyperthyroidism (overactive) Thyroid nodules

Any cancer? No Yes

Breast cancer Prostate cancer Bowel cancer Lung cancer

Other:

OTHER CONDITIONS

List any other medical conditions not covered above:

Condition Details

PAST SURGERIES

List past surgeries:

Surgery Details	Year

FAMILY HISTORY

Adopted (list only info known re. biological relatives)

Please list close relatives and rough ages (or age at time of death). Especially list any history of heart disease, sudden death, diabetes, cholesterol, high BP, cancer.

Relation	Status	Age	Medical conditions / Cause of death