CONFIDENTIAL

If you have any questions or would like to speak to someone about filling out this form, please ask a staff member by calling 416.231.7070 ext. 307

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* Address

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* I have no fixed address

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* Preferred Contact:

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* Email address:

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* May we leave a voicemail on the main contact number?:

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* Emergency Contact:

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* Health Card #

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* Version Code :

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* Expiry Date:

Date

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* Select one in case of no Health Card#

  Yes No
Uninsured
I am in the 3-month waiting period for OHIP

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* Allergies

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* Dietary restrictions:

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* Medical Conditions:

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* PROGRAMS AND SERVICES AVAILABLE: Please check all programs you are interested in.

Socio-Demographic Information:
We Ask Because We Care

We are collecting social information from clients to find out who we serve and what unique needs our clients have. We will also use this information to understand client experiences and outcomes.  ALL INFORMATION COLLECTED IS KEPT STRICTLY CONFIDENTIAL.

 Do I have to answer all the questions?  No. The questions are voluntary and you can choose ‘prefer not to answer’ to any or all questions. This will not affect your care/service.

 Who will see this information? This information will be visible only to your providers and protected like all your other health information. If used in research, this information will be combined with data from all other clients and no one will be able to identify any of the clients.

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* #1. What language would you feel most comfortable speaking in with your health care provider?   Check ONE only

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* #2. If you chose a language above that is not English or French, which of Canada's official languages are you most comfortable with? Check ONE only.

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* #3. We can provide free interpretation for your appointments/programs at Stonegate. Would you like an interpreter?

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* #4. Were you born in Canada?

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* If NO, what country were you born in?

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* If NO, what year did you arrive in Canada?

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* #5. Citizenship Status:

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* #6. Are you here on VISA ?:If yes is it a

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* #7. What is your highest level of education completed? Check ONE only

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* #8. Which of the following best describes your racial or ethnic group? Check ONE only

 If you are 18 years of age or older, please also answer the following three questions:

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* #9. Gender Identity:

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* #10. What is your sexual orientation? Check ONE only if you are 13 years of age or older

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* #11. What was your total family income before taxes last year? Check ONE only

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* #12. How many people does this income support?

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* #13. What is your household composition? Check one that apply

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* #15. What kind of housing do you live in? Check one that apply

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* #16. Do you have any of the following? Check ALL that apply

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* #17. How would you describe your sense of belonging to the community?  Check ONE only

(Sense of belonging is feeling like you are part of something, connected and accepted)

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* #18. In general, would you say your overall physical health is:

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* #19. In general, would you say your overall mental health is:

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* # Do you have children attending programs at Stonegate CHC?

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* Child 1

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* Child 2

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* Child 3

If you are requesting clinical services, please also provide the following information:

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* #20. Do you have a family Physician?

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* #21. Are you pregnant?

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* #22. Do you have family members who are clients of Stonegate Family practice?:

 
Thank you

T