Welcome — we’re glad you’re here.

This is where we get to know you a little, so Dr. Smith and the DSPI Care Team can prepare thoughtfully for your visit.

Go at your own pace. If something doesn’t apply to you, simply skip it — there are no wrong answers.

About 5–7 minutes Move forward and back anytime

About you

Let’s start with the basics.

A few details so we know who we’re caring for.

First name

Middle name (optional)

Last name

Preferred name (what should we call you?)

Gender

Male Female Other

Date of birth

Select your birth month, then type the day and year — for example, April, 19, 1963.

Marital status (optional)

Single Married Divorced Separated

Preferred language

English French Other

Interpreter needed?

Yes No

Reaching you

How can we stay in touch?

We’ll use this to confirm your consultation and share anything you need.

Cell phone

Email

Home phone (optional) Same as cell

Work phone (optional) Same as cell

How would you prefer we reach you?

Cell phone Email Home phone

May we leave a voicemail on your preferred number?

Yes No

Home address

City

Province / State

Postal / ZIP

Country

Canada and the United States are pinned to the top; the full list follows.

Your pharmacy

Where should we send prescriptions?

So Dr. Smith can send any prescriptions straight to your pharmacy — no extra trips or phone calls for you.

Pharmacy name

Pharmacy location

Pharmacy fax number

A few quick ways to find it: search the pharmacy’s name and location along with the word “fax” online, check a prescription label or receipt (it’s often printed there), or call the pharmacy and ask.

The reason you’re here

Where are you experiencing pain?

Choose every area that applies — this helps us focus your consultation.

Other — please describe (a few sentences, if you like)

Your diagnosis

Has a physician given you a diagnosis?

Select any that have been made. If you’re unsure, skip ahead — we’ll sort it out together.

Other

Your care team

Who else is involved in your care?

Your family doctor, specialists, or physiotherapists — and someone we can reach in an emergency.

Providers

Emergency contact

Medical history

A little of your history.

This helps us keep your treatment safe. Share what you can.

Have you ever had cancer?

Yes No

If yes, what type? (optional)

Cancer-free more than 5 years?

Yes No N/A

Have you been diagnosed with, or ever had, any of these?

Other medical conditions

Past surgeries (related to the area you’d like us to treat)

Medications & treatments

What are you taking, and what’s been tried?

Include prescriptions, over-the-counter medicines, and supplements.

Blood thinners & anti-inflammatories

Are you allergic to iodine or contrast dye?

Yes No

Allergies (medications you can’t take)

No known medication allergies

Treatments you’ve already tried

Steroid injection — date (if any)

Other treatment (please describe)

Current medications

I’m not currently taking any medications

Imaging & tests

Any scans or tests so far?

Add each study you’ve had — these help Dr. Smith prepare for your visit.

Do you currently have a PocketHealth account?

Yes No

Your studies

A few quick MRI safety questions

Do you have any of the following?

A little about you

Last few — and they’re easy.

A bit about your day-to-day, and how you found us.

Occupation (present or previous)

Employer (optional)

Work status

Full-time Part-time Light / limited duty

How did you hear about us?

Anyone we should thank? (name, optional)

Almost done

A quick look before you send.

Take a moment to confirm. You can edit any section — nothing is locked.

That’s everything we need. When you’re ready, send it our way and we’ll take it from here.

✓

Thank you.

We’ve received your information. Our team will review it and reach out to arrange your consultation.

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