Ontario adult assessments

Everyday health assessment.

Choose a concern and answer the questions that follow. A doctor will review your submitted assessment and contact you if they have questions or need more information.

Save and return later

Pick the condition first.

After you choose your concern, the next section automatically changes to the questions most relevant to that concern.

18+ onlyOntario focusedDoctor review

Privacy & consent

Your answers help the doctor review your concern and plan any follow-up. Your answers are stored with restricted access. Team notification emails contain only a reference number, not your health information. Read the privacy notice.

About youUse current contact details so we can reach you if needed.

Full nameEmailPhone optionalAge range

Are you currently located in Ontario?

A regulated professional must confirm your identity and location before providing virtual care.

Choose your concernSelect one concern. You can read definitions on the everyday health page.

Which concern would you like reviewed?

Questions for this concernThe questions below change based on the concern you selected.

Choose a concern above to continue.

Overall, how long have the symptoms been present?How are the symptoms changing?Have you already tried self-care or a non-prescription product for this concern?

Medical history, medicines & allergiesOnly provide details when they apply.

Do you have any ongoing medical conditions or significant past surgeries?Do you take any prescription medicines regularly?Do you have any medication allergies or previous serious medication reactions?Have you been admitted to hospital or visited an emergency department in the last 12 months?Do you have a regular family doctor, nurse practitioner, or other primary-care provider?

Final notes & consentReview these acknowledgements before submitting.

Anything else the reviewing doctor should know? optionalI confirm I am 18 years of age or older and I am submitting this information for myself.I understand what information is being collected and why, and I consent to RefyllRx using it to coordinate and support review by the doctor and care team. I may choose not to submit this form.I understand that my identity must be confirmed before virtual care is provided.I understand that my current location must be confirmed before virtual care is provided.I understand this form is not monitored for emergencies and I should call 911 or seek urgent care for severe or rapidly worsening symptoms.

Submitting this form does not create a clinician-patient relationship and does not guarantee treatment or a prescription.