Personal Health History Form
Completing the Form
We ask that you complete and submit the personal health history form prior to your first visit to the cancer centre.
Click here to download the health history form.
To complete the form, you can:
- Print the form and fill it out by hand; or
- Fill out the form electronically. To make the form a fillable PDF, save it to your computer (we do not recommend saving the form on a public computer). You will require Adobe Acrobat Reader DC. Adobe can be downloaded free at https://acrobat.adobe.com/ca/en/acrobat/pdf-reader.html
This form is three pages in length and will take approximately 15-30 minutes to complete. Please complete all sections as thoroughly and accurately as possible. If information is missing, we may need to call you in advance of your appointment to follow up. Your care team will review all of the information that you have provided at the time of your appointment.
Submitting the Form
Once your form is complete, email it to firstname.lastname@example.org. Please include your town/city in the subject line of the email. After emailing the form, you will receive an automated notification confirming that your form has been received. NOTE…this email will not respond to inquiries.
For general inquiries, email email@example.com. While we make reasonable efforts to safeguard your personal information once we receive it, no transmission of data over the Internet or any other public network can be guaranteed to be 100 per cent secure.