MEDICAL EVALUATION FORM

CAN ONLY BE FILLED BY A DOCTOR OR NURSE

Dear Caregivers,

We thank you for your involvement in this admission process. This applicant must be medically assessed as a potential participant in Isuarsivik’s six-week recovery program. This program was designed for people who are physically and mentally able to take part in individual and group counseling and outings on the land. This form is also available in French, but we ask that you please answer the questions in English. 

Your opinion will be highly considered for the selection process.

Your three options to complete the form:

Fill

the online evaluation form below

Download

the fillable Evaluation Form (PDF)

Print

the Evaluation Form (PDF) 

ONLINE MEDICAL EVALUATION FORM

Make sure your Internet connexion is stable and safe to complete this questionnaire.

  • If you have any questions while filling this form, do not hesitate to call us at 1-866-964-9994 and ask to talk to the Admission and Intake Worker. You can also email us at intake@isuarsivik.ca.
  • We ask that you provide the answers either in English or in Inuktitut.

    Applicant's Information / ᑕᑕᕐᓭᔫᑉ ᖃᐅᔨᒪᔭᐅᒋᐊᓕᖁᑎᖏᑦ / Information sur le candidat


    Man / ᐊᖑᑎ / HommeWoman / ᐊᕐᓇᖅ / Femme

    Caregiver's Information / ᑲᒪᔨᐅᑉ ᖃᐅᔨᒪᔭᐅᒋᐊᓕᖁᑎᖏᑦ / Information sur la personne soignante

    Applicant's Health Condition / ᑕᑕᕐᓭᔫᑉ ᐃᓗᓯᒃᑯᑦ ᖃᓄᐃᓐᓂᖓ / État de santé du candidat


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui


    No / ᐊᐅᑲ / NonYes / ᐋ / Oui



    No / ᐊᐅᑲ / NonYes / ᐋ / Oui