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2155 Lawrence Ave East Toronto M1R 5G9
1217 Barnswallow Court Mississauga L5V 2J6

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Intake form

Home / Intake Form

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 History

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.

Medical Doctor Name

Medical Doctor Phone

Health Concerns

Please list your main health concerns in order of importance:

Current Medications

Please list all prescription and non-prescription medications:

Use this pattern
M1 D1 T1
M2 D2 T2
M3 D3 T3

Medication

Dosage

When did you begin this medication?

Previous Long-Term Medications (taken > 6 months)

Medical & Surgical History

Past Injuries or Surgeries (with dates):

Kidney stones

Prostate issues Impotence STDs Genital sores

Known Food Allergies/Intolerances:

Environmental Allergies/Sensitivities

How many times/week do you eat meat/chicken?

Taste preference

Spicy Sour Sweet Salty Other

Preferred season:

Summer Winter Spring Fall

Appetite

High Good Fair Low

Nausea or bloating after eating?

Yes No

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

Urine color

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

Do you exercise?

Yes No

If yes, how often? In Hours/week?

Type/Intensity

Energy level (1–10):

Sexual Health (Confidential):

Do you Satisfied with sex life?

Yes No

Do you wish you were having more sex?

Yes No

Sex frequency:

Weekly Less than monthly

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

Appointment Booking

I would like to book an appointment

Toronto Clinic
📞 (416) 778-1390
✉ info@chaudhryclinic.ca
📍 2155 Lawrence Ave East, Toronto, ON M1R 5G9

Mississauga Clinic
📞 (416) 778-1390
✉ chaudhryclinic@hotmail.com
📍 1217 Barnswallow Court, Mississauga, ON L5V 2J6

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Tornoto Clinic

2155 Lawrence Ave East Toronto M1R 5G9

Mississauga clinic

1217 Barnswallow Court Mississauga L5V 2J6

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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Home
Homeopathy
Hijama & Cupping
Acupuncture
Services
Shop
Practitioners
- Practitioner Muhammad Yaqub
- Practitioner M.Mudasser chaudhry
Blog
Book An Appointment
Intake Form
About us
Contact Us

Book An Appointment