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MoTish Integrated Health

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Patients Intake Form * Patients Intake Form * Patients Intake Form *

Patient Intake Form

Please complete the information below for MoTish Integrated Health Center.

Our Address

MoTish Integrated Health Center, 105-2362 Whatcom Road Abbotsford, BC

Phone Number

+1 604-210-5872

Patient Intake Form

Please complete the information below for MoTish Integrated Health.

Patient Information

Name
Name
First Name
Last Name
Gender

Medical History

Name
Name
First Name
Last Name
Gender

Preventative Health & Lifestyle

Do you smoke?
Do you drink alcohol?
Do you use any recreational drugs?
Do you exercise regularly?

Personal Information

Marital Status

Medications & Allergies

Please bring a list of your medications
please bring a list of over-the-counter medications such as herbal products, vitamins and other non-prescriptive medications

When Did You Last Have the Following?

Enter the year if you recall it.