Patient Form Please Fill The Following Form Carefully. This Form is ONLY accessed by the Practitioner Imran Ansari MBBS, RMP Pakistan. IMG Pakistan. Natural Medicine Practitioner D.N.M. (Canada). We Follow highest possible privacy policy. Patient Name Contact No Email (Optional) Address City Gender --Please Select-- Male Female Marital Status Number of Children Occupation Occupation HEALTH CONCERNS: Please list your health concerns in order of importance. Medications: List all prescription and non-prescription medications you are currently taking. Any other information you want to share? Please check any of the following that apply to you: GENERAL Sores in mouth Fatigue Mercury fillings Change in appetite Jaw pain or clicks Change in thirst Recurrent sore throat Cravings Enlarged glands Weight loss Enlarged thyroid Poor sleep Facial pain Chills or fever Headaches Night sweats GASTROINTESTINAL Nausea Vomiting Vomiting blood Reflux or heartburn Constant hunger Ulcer Gall stones Constipation Diarrhoea Chronic laxative use Rectal burning/pain Haemorrhoids Blood in stool CARDIOVASCULAR Chest pain Palpitations High blood pressure Low blood pressure Heart attack Congestive heart failure Irregular heartbeat Pacemaker Artificial heart valve Fainting Varicose veins Deep leg pain Cold hands or feet Anemia Easy bruising SKIN AND HAIR Dryness Rash Itching Eczema Psoriasis Acne Hives/allergic reactions Recent moles Loss of hair Thinning hair Dandruff Other skin problem(s) NEUROLOGICAL Anxiety Depression Irritability Emotional problems Loss of balance Poor memory Dizziness Seizures/Epilepsy Concussion Lack of coordination Extremity numbness Extremity tingling Paralysis RESPIRATORY Difficulty breathing Chronic cough Bronchitis Emphysema Asthma Wheezing Coughing blood Phlegm in throat EYES, EARS, NOSE & THROAT Eye pain Eye strain Blurry vision Impaired vision Cataracts Ear aches Ear infections Ringing in ears Vertigo or dizziness Sinus infections Nasal obstruction Post nasal drip Nosebleeds Loss of smell/taste Tonsillitis INFECTION Strep throat Mononucleosis Hepatitis MUSCLE, BONE & JOINTS Neck pain Back pain Arthritis Bursitis Joint pain or stiffness Artificial joint Muscle pain Muscle weakness URINARY Frequent urination Urgency to urinate Incontinence Pain on urination Wake at night to urinate Urinary tract infection Blood in urine Kidney stones FEMALE REPRODUCTIVE Do you get yeast infections? Breast tenderness History of abnormal pap? Cravings Are you menopausal? Hot flashes Disrupted sleep Heavy flow Poor memory Light flow Changes in mood Clotting Low libido Bleeding between periods Pain during intercourse Pain or cramping Vaginal itching Vaginal dryness Bloating Headaches MALE REPRODUCTIVE Impotence Infertility/Low sperm count Prostate condition DYSFuction Premature Ejaculation submit