Current clinic dates for M Salim Khan: See
https://mohsinhealth.appointlet.comPlease take about 20mins-30mins to fill out this form. All questions are to be answered by the patient (or on behalf of the patient by a trusted family member or carer.)
Important: Before filling out this form, please make sure that 1) You have all your existing medicines and supplements on-hand, and 2) That you have kept a 3-day food diary of everything you eat and drink and what times for 3 consecutive days. You will need to provide this information on this form.
(Alternatively, if you prefer to fill out the forms by hand, or in your word processor, you can download these on our website or collect them from our clinic.)
The information that you give us on this form is necessary for your practitioner to make a full assessment of your health and wellbeing, and will contribute to informing the treatment plan that is put together for you.
CONFIDENTIALITY NOTICE: ALL PATIENT DATA IS HELD AS STRICTLY CONFIDENTIAL BY MOHSIN HEALTH, 446 EAST PARK ROAD, LEICESTER, LE5 5HH, UNITED KINGDOM, REGISTERED AS A LIMITED COMPANY IN ENGLAND & WALES #06461476. WE DO NOT SHARE YOUR INFORMATION.
