Mohammad Yaqub
Mudasser Chaudhry
Registered Chinese Medicines Practitioner
Registered Homoeopath
Registered Acupuncturist & Herbalist

Hijama Practitioner 

Patient Intake Form
Job Details
Merital Details
Emergency Contact Details
Medical Doctor Details
This is a confidential record of your medical history and will be kept in this office. Information contained in it will not be released to any person unless authorized by you.
Health Concerns
Medications Details
Please list all prescription and non-prescription medications you are currently taking respectively:
Use this pattern
M1     D1     T1
M2     D2     T2
Medical History
Food and Drink
How many cups/bottles/glasses do you drink, on average, per day?
Stools and Urine
Personal Habits and Lifestyle