Health Review Request · Dr. Blinkhorn & Dr. Whiting Family Practice

Who is your physician? *

Dr. David Whiting

Family Physician · In-office Monday, Tuesday, Wednesday mornings

Dr. Blinkhorn

Family Physician · In-office Wednesday afternoons, Thursday, Friday

Your Information

Full Name *

Date of Birth *

Health Card Number (CPN) *

Phone (if changed)

Your Request

Please briefly describe what you are hoping to address. Our office team will pass this along to Dr. Blinkhorn.

What are you hoping to address? *

Your Information

Full Name *

Date of Birth *

Health Card Number (CPN) *

My phone number has changed

Sex at Birth *

This is used to determine which screening tests are relevant for you.

Last Checkup

Approximately when did you last have a checkup? A rough estimate is fine — e.g. “about 2 years ago” or “2022”

Smoking History

Do you smoke, or have you smoked in the past?

Packs per day e.g. 0.5, 1, 1.5

Years smoked Approximate total

Pack-years Calculated automatically

What Are You Hoping to Address? *

I have a specific problem I want to address

A symptom, concern, or change you have noticed that you want investigated.

I feel well — I want a preventive health check

No specific complaints. You would like to review your screening status and make sure you are up to date.

I have an ongoing health problem and it is time for my follow-up

You are being managed for a chronic condition and feel it is time for a review.

Tell Us About Your Concern

Describe your symptom or concern in your own words * As much or as little as you like. This is just to help Dr. Whiting triage your visit.

Screening History

Please indicate which screenings you have had done. Approximate year is helpful but not required.

Please select your sex at birth above to see your personalised screening list.

Conditions Being Managed

Please select all that apply.

Hypertension (high blood pressure)

Diabetes

Chronic kidney disease

Congestive heart failure

COPD (chronic obstructive pulmonary disease)

Cancer survivor

Organ transplant recipient

Screening Review

Your screening status will also be reviewed at this visit alongside your chronic condition follow-up.

Please indicate which screenings you have had done. Approximate year is helpful but not required.

Please select your sex at birth above to see your personalised screening list.

Anything Else

Is there anything else you would like Dr. Whiting to know before your appointment? Optional

Periodic Health Review Request