Intake Form - Chaudhry Clinic

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Mississauga clinic

1217 Barnswallow Court Mississauga L5V 2J6

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Services
Practitioners
Blog
Shop
About Us
Intake Form
Contact Us

Book An Appointment

Toronto clinic

2155 Lawrence Ave East Toronto M1R 5G9

Mississauga clinic

1217 Barnswallow Court Mississauga L5V 2J6

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Book An Appointment
Services
Practitioners
Blog
Shop
About Us
Intake Form
Contact Us

Book An Appointment
Services
Practitioners
Blog
Shop
About Us
Intake Form
Contact Us

Book An Appointment

Book An Appointment
Services
Practitioners
Blog
Shop
About Us
Intake Form
Contact Us

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

Hijama Practitioner

Patient Intake Form

Name

Address

City

Province

Postal Code

Phone (Home)

Phone (Work)

Cell Number

Email

Gender

Male Female

Date of Birth

Job Details

Occupation

Employed By

Merital Details

Marital Status

Number of children

Emergency Contact Details

Emergency Contact

Phone

Relation

Medical Doctor Details

Medical Doctor Name

Medical Doctor Phone

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

What are your main health concerns in order of importance to you?

Medications Details

Please list all prescription and non-prescription medications you are currently taking respectively:

Use this pattern
M1 D1 T1
M2 D2 T2

Medication

Dosage

When did you begin this medication?

Please list all prescription medications you have taken in the past for longer than six months. Indicate how long you took each medication.

Medical History

Please list any injuries and/or major surgery you have had and when they occurred:

Please list any major illnesses or diseases that you have or have had:

General 1(low)-10(High)

Energy levels Appetite Thirst Like to drink cold drinks Like to drink warm drinks Quality of sleep Chills or fever Night sweats Sweat easily Allergies Cancer Diabetes

Skin and Hair

Dryness Rash Itching Eczema Psoriasis Acne Recent moles Hives or allergic reactions Loss of hair Thinning hair Dandruff Other skin problem

Eyes Ears Nose & Throat

Eye pain Impaired vision Night vision, floaters Ear aches Ear infections Ringing in ears Vertigo or dizziness Sinus infections Nasal obstruction Nosebleeds Loss of smell/taste Sores in mouth Jaw pain or clicks Recurrent sore throat Tonsillitis Enlarged glands Enlarged thyroid Facial pain/tics Headaches

Cardiovascular

Chest pain Palpitations High blood pressure Low blood pressure Stroke Fainting Varicose veins Deep leg pain Cold hands or feet Swelling of limbs Anemia Easy Bruising

Respiratory

Difficulty breathing Shortness of breath Chronic cough Bronchitis Emphysema Asthma Wheezing Coughing blood Phlegm in throat Harder to Inhale Harder to exhale

Muscle Bone & Joints

Neck pain Back pain Arthritis Bursitis Joint pain or stiffness Artificial joint Muscle pain Muscle weakness Hernia

Gastrointestinal

Nausea Vomiting Vomiting blood Reflux or heartburn Constant hunger Ulcer Indigestion Abdominal pain or cramping Bloating Gall stones Liver disease Jaundice Intestinal parasites Gas Constipation Diarrhea Chronic laxative use Rectal burning/pain Hemorrhoids Blood in stool

What is the emotion that you experience when you are off?

Loss of balance Poor memory Dizziness Seizures/Epilepsy Concussion Lack of coordination Extremity numbness Extremity tingling Paralysis

Infections

Strep throat Mononucleosis Tuberculosis Hepatitis HIV/AIDS Tendency to catch flues all seasons?

Urinary

Frequent urination Urgency to urinate Incontinence Pain on urination Waking at night to urinate Urinary tract infection Blood in urine Kidney stones

Male Reproductive

Prostate problem Impotence Sexually transmitted disease Sores on genitals

Female Reproductive

Prostate problem Impotence Sexually transmitted disease Sores on genitals

Pain

Do you have any pain at the moment, and where is it located:

Head Arms Back Front Legs Hands Feet Abdomen Other

Specify If any

When did this pain start?

Describe the quality of the pain:

Sharp Radiating Localized Moving Dull Itchy

When does the pain become stronger, and when does it become better:

Morning Afternoon Evening Night

What makes the pain feel better?

Moving Rest Heat Cold Pressure

Food and Drink

Diet

Non Vegetarian Vegetarian Vegan

For how long?

Known Food Allergies/Intolerance:

Known Environmental Allergies/Sensitivities:

How Many Times do you have Meat or Chicken a Week?

Which Taste do you prefer

Spicy Sour Sweet Salty Other

Which Season of the year do you prefer

Summer Winter Spring Fall

How is your Appetite

High Good Fair Low

Do you have any Nausea or distention after eating?

How Many Glasses of water do you have a day?

Do you feel thirsty during the day?

Yes No

When you drink, do you Sip or Gulp your drink?

Sip Gulp

Do you have a sensation of dry mouth?

Yes No

How many cups/bottles/glasses do you drink, on average, per day?

Coffee

Tea

Water

Herbal Tea

Milk 2%

Skim Milk

Beer

Wine

Liquor

Fruit Juice

Soft Drinks (diet)

Soft Drinks (regular)

Vegetable Juice

Other

Stools and Urine

How frequent do you have stools:

More than once a day Once a day Once in 2 days More than once in 2 days

How is the consistency of your Stools?

Well formed Loose Dry Diarrhea

It well formed ( like a hotdog )?

Yes No

Does is it have a foul smell?

Yes No

Is it sticky and leaves marks on the toilet?

Yes No

What is the color of you feces?

Yellow Light brown Dark Greenish

How Many time do you Urinate a day?

What is the color of you Urine

Clear Yellow Dark Yellow

Do you urinate at night?

Yes No

If yes, how many Times?

1 2 3 More

Do you have any pain during urination?

Yes No

Personal Habits and Lifestyle

Do you smoke?

Yes No

If yes, how many per day?

Do you use recreational drugs?

Yes No

How many hours of sleep do you get on average?

Do you feel refreshed in the morning?

Yes No

How many hours do you work each day?

Do you often feel overworked?

Yes No

Do you exercise?

Yes No

If yes, how often? In Hours

What do you do for exercise? (Indicate activity, frequency, intensity and duration)

How is your energy level ( 1 – Poor I am tired all the time, 10 – great I feel like I can climb Mount Everest) :

Do you currently feel fulfilled in your sex life?

Yes No

Do you wish you were having more sex?

Yes No

Do you have sex one or more times a week?

Yes No

Do you have sex less than one time a month?

Yes No

Would you rather eat than have sex?

Yes No

Are you content and happy not having sex?

Yes No

Would you consider yourself to be in a sexual drought?

Yes No

Could you easily identify your erogenous zones to your partner?

Yes No

Are you able to reach orgasm when with a partner?

Yes No

Do you have an easier time reaching an orgasm when alone?

Yes No

Have you ever purchased a sex aid?

Yes No

Do you feel confident you know the different parts of your genitalia?

Yes No

Do you know where the perineum is and its function?

Yes No

Have you ever experienced small tears in your external genital area after sex ?

Yes No

Do you keep masturbating a secret from your partner?

Yes No

Do you feel embarrassed or ashamed that you masturbate?

Yes No

Do you masturbate one or more times a week?

Yes No

Do you feel inhibited by your body when having sex?

Yes No

Do you feel poor body image has negatively affected sex with your partner?

Yes No

Do you have sexual fantasies you have never shared with your partner?

Yes No

Are you too afraid to tell your partner you are not happy with your sex life?

Yes No

Do you watch pornography in secret and not tell your partner?

Yes No

Is sex a stress reliever for you?

Yes No

Do you sleep better after you have had sex?

Yes No

Want to Book An Appointment

Book Appointment

Toronto clinic

(416) 778-1390
info@chaudhryclinic.ca
2155 Lawrence Ave East Toronto M1R 5G9

Mississauga clinic

(416) 778-1390
chaudhryclinic@hotmail.com
1217 Barnswallow Court Mississauga L5V 2J6

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