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UAHLP Intake Form
UAHLP Intake Form
admin
2021-03-24T16:34:09+00:00
Healthy Living (HL) Program Intake Form
Have you completed the Universal Consent Form?
*
Yes
No
Name
*
First
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Phone
Email
Address
*
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
What is your relationship to your emergency contact?
Gender (check all that apply)
*
Male
Female
Transgender
Two-spirit
Non-Binary
Other
Preferred Pronouns
First Language
*
Second Language
Do you have any allergies?
*
yes
No
Please List your allergies
Do you have any Health Condition That Would Require Medication Being Administered During Programming?
*
yes
No
List the medications required and used:
Do you have any Medical or Health Issues That Can Impact Program Participation?
*
yes
No
Any Accommodations to Participate in Activities? If So, Please Describe:
Do you have diabetes?
yes
No
Do you have a family history of diabetes?
yes
No
Tobacco Relationship:
*
Currently engages with commercial tobacco (Cigarettes, E-Cigarettes, Vaping Products etc.)
Currently engages with traditional tobacco practices and/or knowledge
None
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