REFUGEE AND NEWCOMER HEALTH INTAKE

Patient: [Name, preferred name, date of birth, and whether the birth date is approximate]
Visit: [Date, visit 1, 2, or 3, in person or virtual]
Clinician: [Name, credentials]
Language: [Preferred language and dialect, and whether they read it]
Interpreter: [Professional interpreter's name or ID, language, in person, phone, or video; family members and children not used]
Others present: [Settlement worker, sponsor, family member, or none, with the patient's agreement]
Consent: [Confidentiality explained, the right to skip any question, and the patient's questions]

MIGRATION AND STATUS
Country of origin: [Country and region]
Journey: [Countries lived in or passed through, with dates, and camp or city settings]
Arrival and status: [Date and city of arrival; government-assisted refugee, privately sponsored refugee, refugee claimant, protected person, or other newcomer]
Family: [Who came together, who is still abroad, and plans to reunite]
Immigration medical exam: [Date and place, chest x-ray, HIV and syphilis results if done, and any medical surveillance referral]

COVERAGE AND ACCESS
Coverage: [IFHP with UCI, provincial health card and its start date, or both]
IFHP benefits: [Basic, supplemental, and prescription coverage, and the co-payments explained]
Pharmacy: [Name and phone, registered with IFHP]
Settlement support: [Settlement agency or sponsor group, contact name and phone]

HEALTH HISTORY
Concerns today: [In the patient's words, through the interpreter]
Past illnesses: [Malaria, TB or TB contact, hepatitis, and treatment received abroad]
Injuries, surgery, and hospital stays: [Year, country, and reason, as much as the patient wants to share]
Medications: [Current medicines, including those bought abroad and traditional remedies, and any that ran out]
Allergies: [Substance and reaction, or none known]
Family history: [Diabetes, high blood pressure, TB, hepatitis B, blood disorders, and others]

IMMUNIZATIONS
Records: [Written record with dates, camp or travel card, or none; no written record means unimmunized]
Given today: [Vaccine, dose number, and site]
Catch-up plan: [Each vaccine still due with its date, per the Canadian Immunization Guide and your provincial schedule]

SCREENING BY REGION AND RISK
Tuberculosis: [TB incidence in the country of birth, risk factors, test and date, on the same day as any measles vaccine or 4 weeks after]
Hepatitis B: [HBsAg, anti-HBc, and anti-HBs, or results already on file]
Hepatitis C: [Antibody if from a region with higher prevalence or other risk]
HIV and syphilis: [Immigration medical exam result, or test offered with consent]
Strongyloides and schistosoma: [Serology by region of origin, and any eosinophilia]
Iron: [Hemoglobin and ferritin for women of reproductive age and children aged 1 to 4]
Blood pressure and diabetes: [Blood pressure today, and A1c or fasting glucose by age and risk]
Vision and hearing: [Visual acuity in each eye, and hearing screen or concerns]
Dental: [Pain, visible decay, gum disease, and the dental referral]

MENTAL HEALTH AND SAFETY
Approach: [Why we ask explained, the patient chose what to share, no pressure to describe trauma]
Symptoms: [Sleep, mood, nightmares, startle, worry, and body symptoms, with any scores]
Risk: [Thoughts of suicide or self-harm, and safety at home]
Strengths: [Faith, family, community, and what has helped them cope]

WOMEN'S HEALTH
Pregnancy and contraception: [Last period, pregnancies and births, pregnancy test if needed, and contraception wishes]
Cervical screening: [Last test and result, or never screened, and the plan under your provincial program]
Genital cutting: [Asked when relevant and when she is ready, with any symptoms, or not yet discussed]

CHILDREN
Growth: [Height, weight, BMI, and head circumference under 2, on WHO growth charts]
Development: [Milestones in the first language, and any concerns]
School or child care: [School, grade, language support, or child care]

CHRONIC CONDITIONS
[Each condition: when and where diagnosed, treatment abroad, control today, and the plan]

SOCIAL NEEDS
Housing: [Temporary or permanent, who lives there, and safety]
Food and income: [Food security and source of income support]
Language, school, and work: [English or French classes, past work, and goals]
Getting to care: [Transportation to visits, and the best way to reach them]

ASSESSMENT AND PLAN
Problems found: [Numbered list]
Tests ordered: [Each test and the reason]
Treatment started: [Medicine, dose, and length]
Referrals: [TB clinic, dentist, eye care, mental health, settlement agency, or specialists]
Follow-up: [Next visit date, interpreter booked, and what will be reviewed]

RESULTS REVIEW
[Each result with its date, what it means, and the decision made]

Signed: [Clinician name, credentials, date and time]