Je prépare mon rendez-vous de santé

Préparermonrendezvousdesanté
Informationsadministratives:
Prénometnom:____________________________________ 
Datedenaissance:_____________________
Adressepostales:__________________________________
Numérodetéléphones:Maison:_____________________
Cellulaire:_____________________
Adressecourriel:___________________________________
Aidantnaturel:_____________________________________
Gestionnairedecas:________________________________
Nomdevotrepharmacie:____________________________
Àapporter:
● Listedemédicamentsdelapharmacie;
● Carted’assurancemaladieetcarnetdevaccination;
● Sivousfaitesdudiabèteoudelahautepression,veuillezapporterquelqueschiffres
delamaisonet/ouvotrecarnetdesuivi.
1) Mespréoccupationset/oulesquestionsquejedésireaborderlorsdelarencontre:
1:________________________________________________________________________
__________________________________________________________________________
2:________________________________________________________________________
__________________________________________________________________________
3:________________________________________________________________________
__________________________________________________________________________
Nomdesmédecins/spécialistes/autresprofessionnelsquimesuivent:
Noms
Spécialitésetraisonsde
consultation
Datedeladernière
rencontre
// 
an/mois/jour
// 
an/mois/jour
// 
an/mois/jour
Veuillezcomplétersurlapagesuivantevosproblèmesdesantéainsiquevos
antécédents:

Maladiecardiovasculaire:
□Hypertensionartérielle(hautepression)
□Infarctus/Angine
□Insuffisancecardiaque/Eausurles
poumons
□Dyslipidémie/Cholestérol
□Arythmie:_____________________
□Accidentvasculairecérébral(AVC)
□Thrombophlébite
□Autre:________________________
Maladiepulmonaire:
□MPOC/Emphysème/Bronchite
chronique
□Asthme
□Emboliepulmonaire
□Autre:________________________
Maladieendocrinienne:
□Diabète:Type___
□Thyroïde:__________
□Autre:________________________
Maladiedigestive:
□MaladiedeCrohn
□Coliteulcéreuse
□Syndromeducolonirritable
□Intoléranceaugluten
□Cirrhose
□Hépatite
□Refluxgastriqueoubrûluresd’estomac
□Autre:________________________
Maladiearticulaire:
□Arthrite
□Arthrose:spécifierendroit:________
□Ostéoporose
□Autre:_________________________
Maladiedermatologique:
□Psoriasis
□Eczema
□Cancerdelapeau:______________
□Autre:_________________________
Problèmedesantémentale:
□TDAH
□Dépression:_______________
□Anxiété:___________________
□Troublepanique
□Schizophrénie
□Maladiebipolaire
□Toxicomanie/Alcoolisme:___________
□Anorexie/Boulimie
□Troubledepersonnalitélimite
□Tentativedesuicide
□Autre:__________________________
Maladieneurologique:
□Scléroseenplaques
□Déficienceintellectuelle
□MaladiedeParkinson
□Troubledemémoire:______________
□Alzheimer
□Autre:__________________________
Maladieurologiqueourénale:
□Incontinenceurinaire
□Prostate
□Insuffisancerénalechronique
□Autre:__________________________
Cancer:
□Type:___________________________
___________________________
□Depuis:_________________________
_________________________
□Entraitement:
□Chimiothérapie
□Radiothérapie
□Enrémissiondepuis:______________
Autresproblèmes:
□Troublesdelavision/Nonvoyant
□Diminutiondel’ouïe/Malentendant
□Douleurchronique:spécifier:_______
_________________________________
_________________________________
_________________________________
_________________________________

2)Allergiesetintolérances:
___________________________________________________________________________
___________________________________________________________________________
3)Antécédentsdechirurgie(Ex:Appendicectomie…):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
4)Antécédentsfamiliaux:
*Âgereprésentel’âgedecontractiondelamaladie*
Maladie
Mère
Âge
Père
Âge
Fratrie
Âge
Diabète
Maladie
cardiaque
Ostéoporose
Dépression
Hautepression
Cancer
SiCancer,précisez:□Prostate□Colon/Polypeintestinal□Sein
□Autre:_______________________
5)Habitudesdevie:
Fumezvous?□OUI□NON
Quellequantitéd’alcoolprenezvousparsemaine?_________________________________
Consommezvousdesdrogues?□OUI□NON
Sioui,queconsommezvous?_________________________________________________
6)Datesapproximativesdemesdernierstests(Siapplicable):
Mammographie:
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Glycémie:
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Recherchedesang
danslesselles:
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Ostéodensitométrie:
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PapTest:
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Cholestérol:
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Colonoscopie:
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Autre:
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Mercid’avoircomplétécecourtdocument
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