confidential_intake_questionnaire | Dr. Robin Beardsley MD CCFP

Confidential Intake Questionnaire

Instructions: Complete this form online and click the Submit Button at the bottom to send your information securely to Dr. Robin Beardsley prior to your first appointment.

NOTE: * (indicates required fields)

Patient Information
First Name:*
Last Name:*
Address:
Street Address Address Line 2 City Province Postal Code
Email:
Phone w/ extension if applicable:*
Is your phone textable?
- Yes
- No
Health Card:*
Version Code (if applicable):
Expiry Date:*
Date Format: MM slash DD slash YYYY
Province (Health Card):*
Date of Birth*
Date Format: MM slash DD slash YYYY
Occupation:
In Case of Emergency - Contact Information
Name:
Relationship:
Phone:
Email:
Working with Dr. Robin Beardsley
What are you hoping to change by working with Dr. Beardsley?
Health Concerns
What stressors are you currently managing?
- Job Stress
- Financial Concerns
- Family Concerns
- Parenting Concerns
- Major Life Changes
What Physical Symptoms are you currently experiencing?
What Emotional Symptoms are you currently experiencing?
- Feeling Overwhelmed
- Anger Issues
- Loss
- Anxiety
- Lack of Energy
- Depression
- Feeling Uncertain
- Addiction
- Feeling “Disconnected”
What is it that impacts you the most? How does it present or show up in your life?
How would you like things to be? Think of what you want rather than what you don’t want, or think of what you might need?
Describe the Positive Outcomes that you will experience in your life as a result of creating some changes.
What significant health challenges have you experienced in the past?
What significant emotional challenges have you experienced in the past?
- Anxiety
- OCD
- Addiction
- Frequent Moves
- Loss of a Loved One
- ADHD
- Childhood Abuse
- Eating Disorder
- Parent’s Divorce
- Learning Disability
- Significant Accident or Illness
Family Physician:
Allergies:
Current Medication(s)
Current Medication Dose Frequency Date Started
Past Medication(s)
Current Medication Dose Frequency Dates of Use
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Current Medication	Dose	Frequency	Date Started

Current Medication	Dose	Frequency	Dates of Use

Confidential Intake Questionnaire

Patient Information

In Case of Emergency - Contact Information

Working with Dr. Robin Beardsley

Health Concerns