Actuel Page 1 Page 2 Aperçu Personal health information on this form is collected by Health PEI for the purposes of your care and for other purposes permitted by the Health Information Act, including the planning and management of health services. Your information will be collected, used and disclosed only as permitted by law. For more information, visit www.healthpei.ca/yourprivacy or contact Peter Howatt, Manager, Provincial Palliative Care Centre, 902-368-4781. Identification Is this your first time completing this assessment? - Sélectionner -YesNo Prénom Initiale Nom Adresse 1 Adresse 2 Ville, municipalité, communauté Province Code postal Exemple : C1B 0X1 ou 12345 Pays Numéro de téléphone Exemple : 902-555-5555 Adresse courriel First Name Middle Initial Last Name Telephone Number For example 902-555-5555 What is your age? - Sélectionner -0-1718-39 40-6465-7980+ Assessment completed by - Sélectionner -PatientFamily CaregiverHealth Care Professional CaregiverCaregiver-assisted Regional location - Sélectionner -West PrinceEast PrinceQueensKings Personal Health Number (PHN) Please enter the 8-digits from your PEI health card. Name of Family Physician/Nurse Practitioner (If no Physician/Nurse Practitioner please write none)