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VAC 1416: Family Physician Assessment

Veterans Affairs Canada asks a client's family physician for this general medical assessment, which opens with VAC's reason for referral and ends with information for its health care team. The physician reviews each body system, reports a chest x-ray and basic lab results, describes mental status including competence to handle one's own affairs, and lists current therapy, medications, allergies, diagnoses and prognosis.

Who completes it

The family physician completes items 1 to 16 and signs the form. The identification section covers the client's name, date of birth, provincial health insurance number, spouse, marital status and any service number, along with the VAC district, date and reason for referral.

Good to know

  • Item 8 asks whether a chest x-ray, HGB, FBS, BUN, electrolytes and urinalysis were done, with the result for each and room for other tests.
  • Item 9 covers mental status, including alcoholism and the client's competence to handle their own affairs.
  • Item 13 asks whether the diagnoses are known to the Veteran and to the family, and item 15 whether rehabilitation means maintenance at the present level or deterioration is likely.
  • Items 2 to 7 review head, neck, vision, hearing and speech, then the cardiovascular, respiratory, abdominal and genito-urinary systems, skin and lymph nodes, and muscles, bones and joints including the spine.

Get the official form

Download the current version from the source each time; forms change without notice.

Family Physician Assessment

Évaluation du médecin de famille

Official pagePDFVersion française

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

What tests does VAC form 1416 ask about?

Item 8 lists a chest x-ray, hemoglobin (HGB), fasting blood sugar (FBS), blood urea nitrogen (BUN), electrolytes and urinalysis. For each, you mark whether it was done and give the results, and an extra line covers any other diagnostic test that is relevant to the assessment.

Is the VAC Family Physician Assessment available in French?

Yes. VAC publishes it in English as VAC 1416e and in French as Évaluation du médecin de famille. The current edition is dated 2020-08, runs four pages and is a fillable PDF that VAC lists under Health Care, and you can enter information directly and save it as you go.

What does VAC 1416 ask about treatment?

Item 10 asks for present therapy such as occupational therapy, physiotherapy or speech therapy, item 11 for a list of present medications, and item 12 for drug sensitivities and allergies. Item 14 asks for the prognosis, and item 16 for anything else that would assist VAC's health care team.