By Lily Shengjia Zhong, Last updated September 3, 2025

ID

• 姓名 (Name): ____________________

• 年龄 (Age): ____________________

• 性别 (Sex / Gender): ____________________

• 出生日期 (Date of Birth): ____________________

• 病历号 (MRN): ____________________

• 安省健康保险号码(OHIP #): ____________________

• 联系电话 (Phone Number): ____________________

• 婚姻状况 (Marital Status): ____________________

• 紧急联系人 (Emergency Contact): ____________________

• 与患者关系 (Relationship to Patient): ____________________

• 联系电话 (Contact Phone): ____________________

• 医疗授权代理人 (Power of Attorney, POA): ____________________

• 与患者关系 (Relationship to Patient): ____________________

• 联系电话 (POA Contact Phone): ____________________

主诉 (CC): ____________________________

就诊原因 (RFR): ____________________________________