Patient Classification Form | Silverstream Health Centre

Personal Details

Patient Name*

First name Last name

Email address*

Gender*

Gender diverse*

(please state)

Date of birth*

Height (cm)*

(in centimetres)

Weight (kg)*

(in kilograms)

Mobile Phone

Home Phone

Employment status*

Occupation*

Company name*

Phone number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Status*

If you are a past smoker or recently quit, when did you quit smoking?*

(approximate date acceptable)

If you are a current smoker, how many do you smoke per day?*

If you are a current smoker, would you like support to quit smoking?*

Quantity*

Do you suffer from any of the following

Conditions

Allergies*

Please specify

Do you take Warfarin*

Excluding yourself. Please give details and family member.

Heart problems*

Heart problem details*