AL-HAKIM Homeopathic Center Richmond Hill, Ontario,Canada

Our Clinic : 

Online Homeopathic Pharmacy
In-Person Appointment

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Intake Form

Instructions

You have come here to get well. In order to do that we depend on your information & cooperation.
HOMOEOPATHIC MEDICINE IS MAINLY SELECTED ON THE SYMPTOMS YOU GIVE US. If we are to make a successful prescription, we must know all the details of your sickness. We must also understand all the features that belong to you as an individual. This includes your reactions to various factors, your past and family history and your mental makeup. This information enables us to select the remedy that removes your sickness. The medicine also makes you well as a whole person.
In order find all about you, we shall be asking you many questions. Each one of these questions has a definite meaning and significance for us. There is not a single question that is useless. Even something that you may think is not connected with your trouble may be the most important factor in deciding the correct homoeopathic medicine. That is why you must be free and frank and give us the fullest possible information on each point. Please read each question carefully, think, and if necessary, consult someone close to you and then answer completely. Do not keep anything back. Remember, whatever you tell us will remain absolutely confidential. .

This questionnaire has 8 parts:

  1. About your past illnesses.
  2. History of your present illness.
  3. About all the parts of your body.
  4. Factors that affect your health.
  5. About your mental and emotional state.
  6. About your sleep and dreams.
  7. For children or how you were as a child.
  8. Instructions for reporting your complaints.

Please take time to answer each question carefully before coming to us.

CONFIDENTIAL INFORMATION

Every disease, poisoning, drug or accident leaves its mark and remains as a weak point in the system, much more than we imagine. Homeopathic treatment takes into account all these details of the past and thus removes all the weak points.

Thus your body is strengthened. It is necessary for us to know about all the ailments you have suffered from in the past and the treatments you have taken. In the list below, circle or tick the names of ALL major illnesses you have suffered so far and on the next page give relevant details.

Questions about your birth

Indicate number of times you were vaccinated for the following :

Your Habits How much

Main Present Complaints and Troubles

APPETITE AND THIRST

ANY COMPLAINTS ABOUT

STOOL

URINATION & URINE

SWEAT / PERSPIRATION - FEVER - CHILL

CHEST - HEAT - COLD - COUGH

SEXUAL SPHERE ( GENERAL )

Questions For Men

Questions For Women

Attach your Medical Diagnostics