Point Douglas Pharmacy
885 Main Street
Winnipeg, Manitoba, Canada
R2W 3P2
Toll Free Phone: 1-877-542-3330
Toll Free Fax: 1-877-994-2121

Physician Questionnaire

Dear Physician,

     Your patient has requested to have his/her prescription filled by Point Douglas Pharmacy. In order to complete this request we will require you to print this form and fill out this online questionnaire (you may use the online version) providing information on his/her medical history. We will require this annually and if there have been any significant changes to your patients' health then we will require you to update your patients medical information when they have their next prescription filled. Your patient will be providing signed consent for you to do this by clicking "I Agree" on their online medical questionnaire and disclaimer or by signing the printed version. If you require a copy of the patient questionnaire please contact us:
Toll Free Phone: 1-877-542-3330 or email

     A Canadian licensed physician will review your submission/letter along with the patients' medical questionnaire that he/she will be submitting. All medical information will be treated in a confidential manner. Your cooperation may result in better patient compliance due to the lower cost of the medications. This may benefit your patients' overall health. Please also fax your prescription to the above number.

Physician Information

Patient Information Patient Contact Information Patient Additional Information Your Full Name ___________________ S.S.N. (required for U.S. Customers) _____________________ Date ___________________ Age _____________________ Address ___________________ Height _____________________ City ___________________ Weight _____________________ Email ___________________ Sex  M______ F_______ Phone (Home) ___________________ D.O.B D ___ M ___  Y___ Phone (Work ___________________ Occupation (Optional) _____________________ State ___________________ Retired _____________________ Zip ___________________ Referral Source (Optional) _____________________ If you have previously filled out a questionnaire, please indicate if there are any changes                          Y___      N___    First Questionnaire ____ Family History 1) Diabetes, Thyroid or other     endocrine disorder Y ___ N ___   2) Breast cancer Y ___ N ___ 3) Hypertension (high blood pressure) Y ___ N ___ 4) Cardiovascular (heart or artery     disease) Y ___ N ___ 5) Lipid (cholesterol) disorder Y ___ N ___ 6) Prostate Cancer Y ___ N ___ 7) Other forms of cancer Y ___ N ___ 8) Migraine Headaches Y ___ N ___ 9) Other illness not previously noted Patient Medical History 1) Blood disorders Y ___ N ___   14) Heart disease including       atherosclerosis, angina, heart       failure or history of heart       attack Y ___ N ___   2) Cancer Y ___ N ___   15) Renal or kidney disease Y ___ N ___ 3) Immune disorders Y ___ N ___   16) Liver disease Y ___ N ___ 4) Poor wound healing Y ___ N ___   17) Drug allergies Y ___ N ___ 5) Edema or excessive fluid retention Y ___ N ___   18) Orthopedic or muscle       disorder, including fracture,       joint disorder or carpal tunnel        syndrome Y ___ N ___ 6) Neurological disorders                   Y ___ N ___   19) Emotional disorders   Y ___ N ___ 7) Thyroid, diabetes or other endocrine      disorder,including insulin resistance Y ___ N ___   20) Surgery Y ___ N ___ 8) Any know nutrition deficiency     including minerals and     electrolytes Y ___ N ___   21) Glaucoma   9) Hyperlipidemia (high     cholesterol) Y ___ N ___   22) Chemical dependency Y ___ N ___ 10) Upper respiratory disorders Y ___ N ___   23) Other illness not yet noted Y ___ N ___ 11) Smoker Y ___ N ___   24) Medications used in the last      12 months Y ___ N ___ 12) Lung disorder (i.e., asthma,      emphysema) Y ___ N ___   25) Rheumatoid arthritis, lupus, or       connective tissue diseases Y ___ N ___ 13) High blood pressure Y ___ N ___       Miscellaneous Patient Information 1) How long has the patient been under your care? ____________________________ 2) How frequent are your patient office visits? ____________________________ 3) When was your patient last examined by you? ____________________________     4) Please list all allergies 5) All diagnoses 6) Relevant medical history     including surgery and     hospitalizations   7) Relevant lab tests. For hypercholesterolemia include serum cholesterol results For hypertension include recent BP readings For diabetes include recent blood sugar results For arrhythmias include a recent EKG result or photocopy For hypo/hyperthyroidism include thyroid function tests For asthma or lung disease include a recent spirometry reading and chest x-ray result if available Physician  Signature ___________________________    Date   _________________   Please note, ALL individual pages printed from YOUR printer must be signed and dated.

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