Nasri Functional Medicine Clinic

8333 Weston Road Unit 202, Woodbridge ON, L4L 8E2

730 Essa Rd, Barrie ON, L4N 9E9

Ahmad Nasri, H. D.

Homeopathic Doctor

Medical and Health History

** Fill out and bring this form with you at your appointment time. Do not mail it **

This is an important part of your visit. Accurate completion of this form will assure

that you receive the best care in the time set for your visit. Allow around 60 minutes.

Name__________________________________________, Age _____, Sex _____

Marital Status___________ Address__________________________________________

City ____________ Prov. Postal Code Birthdate ____/_____/_____

Home Tel. ___________________Work Tel M D Y

E-mail___________________________________

Occupation _____________________ Past Occupations __________________________

Name/ Contact number of present physician ____________________________________

Who referred you, or how did you learn of us? __________________________________

Health Card Number ___________________________ Version code ________________

Valid until ___ / ___ / ___ Private Insurance Plan? _____ Name: ___________________

Coverage for Homeopath, Naturopath, Chiropractic, etc. __________________________

Your Height______ Actual Weight ______ Lowest Adult Weight ______ Highest_____

Please describe your major problems &/or symptoms. If none, please write your reason

for seeking this consultation. Include when the symptoms first appeared.

_______________________________________________________________________

If you have seen other physicians, indicate the results of their evaluations:

_______________________________________________________________________

Please bring, if possible, recent medical records, lab tests or diagnostic results.

What habits or activities do you consider to have contributed to any of your problems?

________________________________________________________________________

Do you smoke? ______ How much per day? __________ For how long? ____________

If you stopped, when?____________ Are you a passive smoker? ___________________

Alcohol Use?______ Specify type, quantity and frequency ________________________

Drug Use ( non-medicinal) specify type and frequency____________________________

Caffeine Use: How much of each of the following do you consume?

Regular Coffee_________ Tea_________ Chocolate or cocoa________ Colas_________

Allergies specify name and type of reaction:

Medications______________________________________________________________

Foods___________________________________________________________________

Pollens______________________ Chemical Sensitivities_________________________

Exercise_____ Type______________________ Frequency________________________

Sleep: Hours/night___________ Do you wake during the night?____________________

Problems getting to sleep?_____What time do you go to sleep?_____

Do you have problem going back to sleep?_______ Do you dream?________

Did your mother have any problems during her pregnancy with you?________________

___________________________________Were you bottle or breast fed?____________

Childhood diseases, circle : Mumps, measles, Asthma, Pneumonia, Recurrent Tonsillitis.

Prolonged Antibiotic Therapy? Erythromycin, Penicillin, Tetracycline, Amoxicillin, etc._____________________________________________________________________

Hospitalizations: List admissions, reasons (diagnoses), and surgeries:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Blood transfusions?_______ When:_________________________ How many?:______

Symptom and System Review: Write all the appropriate letters in left hand columns. Do not fill anything if the problem is not applicable to you.

“ C “ for current problem “ I “ for intermittent problem “ P “ for past problem.

___Headaches ___Shortness of breath ___Frequent Urination

___Fainting or dizziness ___Wheezing or Gasping ___Brown or red urine

___Loss of balance, vertigo ___Coughing ___Continual urge to urinate

___Coughing blood ___Burning sensation

___Blurry or double vision ___Chest colds or pneumonia ___Decreased force of urine

___Cataracts ___Involuntary leak of urine

___Eye pain or itching ___High blood pressure ___Difficulty start urinating

___Heart murmurs ___Kidney/Bladder infection

___Hearing loss ___Skipped heartbeat ___Venereal diseases

___Ear pain or Infection ___Racing heart

___Ear noises or ringing ___Chest pain or pressure ___Osteoporosis

___Difficulty breathing at night ___Aching Muscles/Joints

___Dental problems/decay ___Varicose veins or phlebitis ___Arthritis

___Mercury fillings ___Joint stiffness

___Sore/ coated tongue ___Indigestion/ heartburn ___Back or neck pain

___Loss of taste, or smell ___Belching/ bloating

___Cold sores or fever blisters ___Nausea/vomiting ___Weakness on walking

___Abdominal pain/cramps ___Painful feet

___Sinus or nasal congestion ___Constipation ___Leg cramps

___Runny nose/ frequent colds ___Diarrhea ___Numbness or tingling

___Nasal Polyps. ___Rectal itching/pain ___Bleeding/ Bruisin

___Hemorrhoids

___Sore throat/swollen glands ___Fresh blood in stool ___Seizures or Epilepsy

___Recurrent fevers and chills ___Black stools ___Nervousness/ Anxiety

___Difficulty Swallowing ___Jaundice ___Trembling/ Tremors

___Hoarse voice ___Hepatitis/ Pancreatitis ___Had psychological help

___Dry skin ___Colitis/ Crohn’s disease ___Suicidal thoughts

___Acne/Eczema ___Diverticulosis/Diverticulitis

___Weight gain/loss ___Loss of appetite

___Hypothyroid/Hyperthyroid ___Excessive hunger ___Diabetes

-MEN ONLY-

___Acne/ Eczema ___Painful Testicles ___Nipple discharge

___Skin rashes ___Hernia ___Mammograms

___Psoriasis ___Prostate Problems ___Regular Pap smears

___Sexual Dysfunction ___Age first Menstruation

___Hypothyroid/Hyperthyroid ___Regular/Irregular

___Weight gain/ Loss

-WOMEN ONLY- ___Usual Duration

___Feel warm/ cold ___Use birth control? ___Heavy Bleeding/ Clots

___Loss of appetite ___Diaphragm/ Pills/ IUD? ___Spotting/ Fibromas

___Excessive hunger ___Number of Pregnancies ___PMS/ Headaches

___Fatigue or Weariness ___Natural birth/ C section ___Discharge/Itching

___Night sweats ___Breast Lumps ___Menopause

___Diabetes ___Fibrocystic disease ___Hot flashes/mood swings

___Age first Menstruation ___Nipple Discharge ___Regular/Irregular

___Mammograms ___Regular Pap smears

Family History: List medical problems related to your family members. If deceased, their age at death, and cause.

Mother_______________________ Father________________________

Grandmother___________________ Grandmother___________________

Grandfather____________________ Grandfather____________________

Brothers_______________________ Sisters________________________

Your Immunizations: Specify when if known

Smallpox______________ Tetanus_____________ Polio_____________

Flu___________________ Mumps_____________ Measles___________

Pneumonia_____________ Diphtheria____________ Pertussis__________

Living Environment:

House or Apartment________ Old or new___________ Type of heat_______

Humidifier?_______________ Treated for pests_______ What kind_________

Pets, kind________________ Chemical cleaners_______ Close to golf course_

Dietary Habits: Specify foods and beverages you normally consume on a typical day: WEEKDAYS WEEKENDS

Breakfast

Snack

Lunch

Snack

Dinner

Snack

Your Tests: Specify when if known:

Last Physical Exam_________ X-Rays_____________ GI series__________

EKG____________________ Stress Test___________ Ultrasound_________

Angiogram_______________ Catheterization_________ Blood Test_________

Others__________________________________________________________________

Medications: List all prescription medicines or drugs that you are taking. Specify dosages and frequency:

____________________________________ ______________________________

Nutritional Supplements: Specify dosages and frequency:

____________________________________ ______________________________

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any member of his staff responsible for any errors or omissions that I may have made upon the completion of this form.

Signature__________________________ Date: ______________________________

Received by _______________________ Date: ______________________________