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NEW PATIENT FORM for DR MUKHTAR

Personal Information

First Name *

Middle Name

Last Name *

Birth Date *

Email *

Health Card Number *

VC *

Expiry *

Home Telephone *

Cell Phone *

Address *

City *

Postal Code *

Past/Current Doctors *

Medication *

Medical History

PLEASE CHECKMARK YES OR NO TO THE QUESTIONS BELOW:

EPILEPSY (SEIZURES)

YesNo

ANEMIA

YesNo

ARTHRITIS

YesNo

STROKE

YesNo

CANCER

YesNo

BLEEDING DISORDER

YesNo

FIBROMYALGIA

YesNo

ECZEMA

YesNo

MIGRANE HEADACHES

YesNo

ALLERGY CONDITION

YesNo

OSTEOPOROSIS

YesNo

ASTHMA

YesNo

DIABETES

YesNo

GLAUCOMA

YesNo

HIGH BLOOD PRESSURE

YesNo

PSYCHIATRIC ILLNESS

YesNo

HIGH CHOLESTEROL

YesNo

ANXIETY

YesNo

HEART DISEASE

YesNo

INSOMNIA

YesNo

Lifestyle & Medical Information

Tobacco Use Per Week *

Narcotic Used In Past 2 Years *

Allergies *

Alcohol Used Per Week *

Exercise (How Much) *

Surgeries *

Agreement & Signature

I hereby certify that the information provided is accurate and complete. I understand that the doctor-patient relationship may be terminated if inaccurate information is provided or if clinic policies are not followed.

I acknowledge that I have read, understood, and agree to the Terms and Conditions.

Date *

Signature *

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Contact Info:

Phone: (519) 977 4029

Email: doctormukhtar786@gmail.com

Address: 2930 Dominion Boulevard, Windsor, ON N9E 2M8