CUMULATIVE PATIENT PROFILE

Patient: [Name, preferred name, pronouns]
Date of birth: [Date]
Health card: [Province and number]
Contact: [Address, phone, and how the patient prefers to be reached]
Emergency contact: [Name, relationship, phone]
Substitute decision-maker: [Name, relationship, and the document that names them, or not named]
Language: [Preferred language, and whether an interpreter is needed]
Most responsible provider: [Family physician or nurse practitioner, and the practice]
Last updated: [Date, and by whom]

ONGOING HEALTH PROBLEMS
[One line each: the problem, the year diagnosed, its status, the latest key measure with its date, and who manages it]

PAST MEDICAL AND SURGICAL HISTORY
Past illnesses: [Resolved conditions that still matter, with years]
Surgeries and procedures: [Procedure, year, and where]
Hospital stays: [Year and reason]
Pregnancies: [Pregnancies and births, or not applicable]

FAMILY HISTORY
[Relative, condition, and age at diagnosis, and age at death if they have died: heart disease, diabetes, cancers, mental illness, genetic conditions]

SOCIAL HISTORY
Home: [Who lives at home, housing, dependants]
Work: [Occupation, shift work, exposures at work]
Tobacco and vaping: [Never, former with quit date and pack-years, or current with amount]
Alcohol and cannabis: [Drinks a week and the most on one day; cannabis, how often and in what form]
Other substances: [Type and how often, or none]
Activity and eating: [Minutes of activity a week, usual eating pattern]
Supports and stressors: [Partner, family, money, recent life events]

LONG-TERM MEDICATIONS
[Each medicine: name, strength, dose and when, what it's for, who started it, and the start date]
Stopped medicines to remember: [Medicine, date stopped, and why]
Natural health products: [Vitamins, herbal products, supplements, or none]

ALLERGIES AND REACTIONS
[Substance, what happened, the year, and whether it is an allergy or an intolerance, or no known allergies]

IMMUNIZATIONS
[Each vaccine with the date of every dose: Tdap or Td, MMR, hepatitis B, HPV, influenza, COVID-19, pneumococcal, shingles, RSV, travel vaccines]
Source: [Clinic record, provincial record, pharmacy, or the patient's own card]

RISK FACTORS
[Cardiovascular risk with any score and its date, cancer risk from family history or smoking, fracture risk, work exposures, or others]

REMINDERS AND PREVENTIVE CARE DUE
[Each item: last done, the result, and when it is next due, such as cancer screening, chronic disease checks, bone density, or vaccines]
Alerts: [Sick-day medicine rules, medicines to hold before surgery, implanted devices, drugs to avoid]

OTHER CARE PROVIDERS
[Name or role, clinic, phone, and what each one follows, including the pharmacy]

ADVANCE CARE PLANNING
[Wishes discussed and the date, documents and where they are kept, or not yet discussed]

REVIEW
Changes today: [What was added, updated, moved, or removed]
Next full review: [Date or visit]