Intake information

The following information is collected at the time of intake:

  1. Referring Person's Name, Profession, Affiliation, Phone Number

  2. Primary care provider or Case Manager

  3. Patient's Family Name and First Name

  4. Medicare Number, Expiry Date

  5. Patient's Prescription Coverage

  6. Gender

  7. Marital Status

  8. Date of Birth, Age

  9. Patient's Address & telephone number

  10. Patient's physician

  11. Country of Origin, Date of Arrival

  12. Name of children, their ages, dates of birth, occupation/grade

  13. Immigration Status

  14. Mother Tongue

  15. Other languages spoken

  16. Religion

  17. Ethnicity (as defined by patient)

  18. Education

  19. Occupation, Employment Status

  20. Need for Interpreter, Preferred language

  21. Reasons for Consultation ( specification of the cultural problem for which you are seeking consultation; e.g. clarify diagnosis, choice of treatment or therapeutic strategy, difficulty with clinical communication or treatment compliance

  22. What do you expect the Cultural Consultation Service to provide you?

  23. How did you come to know about our service?
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