Choose the Intake Form for Your Care
Cancer Care Intake
For patients beginning integrative cancer care at any stage, including those currently undergoing treatment and those seeking support following treatment.
- Contact information
- Cancer intake questionnaire
- Cancer-specific health history
- Informed consent
- Patient code of conduct
- Release of records
- Cancer care treatment agreement
General Adult Intake
For gut health, women's and men's health, hormones, chronic conditions, medical aesthetics, and optimal health and longevity.
- Contact information
- Adult intake questionnaire
- Full health history and systems review
- Patient code of conduct
- Release of records
Send your completed forms to info@portmoodyhealth.com or fax them to (604) 949-0017, at least one week before your appointment. If it is easier, print the forms and complete them by hand.
Not Sure Which Forms You Need?
Common Questions
No. Please book your initial consultation first, either online or by calling (604) 949-0077. Once your appointment is booked, complete the appropriate intake forms and return them at least one week before your appointment so your physician has time to review your health history in advance.
Yes. You can print the package and complete it by hand, then fax it to (604) 949-0017 or scan and email it to info@portmoodyhealth.com. Many of our patients prefer completing the forms on paper. Please write clearly, and use a separate sheet if you need additional space.
Complete as much as you can. The questionnaire is detailed because it helps your physician understand your health history and overall picture before your first visit. If you are unsure how to answer a question, you can leave it blank and discuss it with your physician during your appointment.
The length of your first visit depends on the type of consultation:
Cancer care with Dr. Sharon Gurm: 45-60 minutes
General first visit with Dr. Paulina Domzal: 75-90 minutes
Subsequent visits: approximately 15-75 minutes, depending on the type of appointment
