AL-HAKIM Homeopathic Center Richmond Hill, Ontario,Canada

Our Clinic :

Unit 30 – 670 Hwy 7 East, Richmond Hill, Ontario, CA

Online Homeopathic Pharmacy

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Homeopathic Consultation Forms

Please Fill the Intake & Consent form

Kindly complete the attached fillable forms and submit them prior to your consultation appointment.

Intake Form

Consent Form

Attach your Medical Diagnostics

Our Homeopathic Clinic and Drugstore is Conveniently Located inside Indoor Shopping Mall “ Shoppes of The Parkway ” Main Floor Shop # 30 – 670 Hwy 7 East, Richmond Hill, ON L4B 3P2

Acute Conditions

Male Heath Issues
Women's Health
Children’s Health
Skin Disorders
Digestive Diseases
Addictions

Chronic Conditions

Autoimmune Disorders
Endocrinal Disorders
Cardiovascular Problems
Nutrition & Metabolic Disorders
Urological Disorders
Skincare (Dermatology)

Contact Info

Shoppes of The Parkway Unit 30 – 670 Hwy 7 East, Richmond Hill, Ontario, CA
ontariohomeopath@gmail.com
+1 (647) 673-4242
+1 (647) 673-4242
Monday to Thursday 12:00 PM to 06:00 PM
Saturday – 12:00 PM to 05:00 PM
Friday & Sunday – CLOSED

Copyright © 2025 All rights reserved

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:

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

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

CONFIDENTIAL INFORMATION

Date:

Full Name:

Address:

Mobile:

Email:

Age:

Gender:

Date of Birth:

Maritial Status:

Diet Preference:

Occupation (Nature of Work)

Education:

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.

Please select if applicable

Typhoid Cholera Food poisoning Worms Diarrhea Dysentery Measles German Measles Chicken-pox Small-pox Mumps Whooping cough Malaria Jaundice Any Liver, Spleen or Gall bladder disease Miscarriage Abortion Sickness during Pregnancy Prolapse of uterus Malnutrition Rickets Rheumatism Backache

Any Venereal disease like Syphilis Gonorrhea etc.:

Any Heart trouble - Blood Pressure - Dizziness

Nephritis (Kidney or Urine trouble) Diabetes etc. - Prostate trouble

Any Surgery such as Tonsils - Abdomen - Appendix - Hernia - Piles - Uterus - Renal stones - Gall stones - Phimosis - Hydrocele - Cataract etc.

Mode of Anesthesia : General - Local

Diphtheria - Septic Tonsils - Adenoids - Recurrent infections - Sinusitis -Bronchitis - Eosinophilia - Cold-Fever - Chill. Pneumonia - Asthma - Pleurisy - T. B.

Any serious shock - grief - disappointments - fright - mental upset - depression or nervous breakdown

Chronic Headaches - Numbness - Cramps - Fits - Convulsions - Polio - Paralysis - Meningitis - Any Lumbar puncture done.

Any major accident - injury to body or head - Any occasion of unconsciousness -Any major bleeding from any part of the body.

Skin diseases like Pimples - Boils - Carbuncles - Ringworm - Fungus - Scabies -Eczema - Herpes - Urticaria - Allergy - Ulcers on any part of the body

Choose One

Grandfather Grandmother Father Mother Uncle Aunt Cousin Brother & Sister

Did any of your relatives have trouble similar to yours

List of major diseases Relationship Alive / Dead Age Diseases suffered Cause of death

Anemia Cancer Diabetes Insanity Rheumatism T.B. / Pleurisy Leprosy Epilepsy / Fits Bleeding tendency Urticaria Eczema Asthma Paralysis Hypertension Heart trouble Kidney disease Liver disease

Questions about your birth

Did your mother have any problem during pregnancy

Did she take any drugs during pregnancy? What were they

Was there any difficulty about your birth? Give Details

At what age did you start Teething

At what age did you start Sitting

At what age did you start Standing

At what age did you start Walking

At what age did you start Speaking

Urine control / bed-wetting problem

Eating indigestible like chalk, lime, earth, slate-pencil etc

Any other problem about your growth & development? Speaking

Tick mark if any animal bites such as:

Dog Rat Snake Scorpion

Did you take anti-rabies or anti-venom or any other treatment

Indicate number of times you were vaccinated for the following :

Smallpox

Polio

Cholera

Measles

Triple B. C. G

Typhoid

Was there any reaction or particular trouble after any of above vaccination or inoculations

Yes No

If yes Give details:

(If married) How is the health of your husband/wife:

Number of children living and dead. If dead, state causes

Mention ages of children and their condition of health

Child’s Name Male/Female Age Disease Suffered

Any abortions, miscarriages or stillbirths

Your Habits How much

Smoking

Snuff

Chewing Tobacco

Alcohol

Tea

Sleeping Pills

Laxatives / Purgatives

Drugs

Main Present Complaints and Troubles

Detailed history of the present illness, the onset and course with dates

Origin of Cause : can you trace the origin of the present illness to any particular circumstance, accident, illness, incident or mental upset (e.g. Shock, worry, errors in diet, overexertion, overexposure to cold, heat etc.)

APPETITE AND THIRST

How is your appetite :

When are you hungry :

What happens if you have to remain hungry for long :

How fast do you eat :

How much thirst do you have :

Any particular time are you specially thirsty :

Do you feel any change in your taste and feeling in your mouth :

ANY COMPLAINTS ABOUT

VERTIGO - Do you have giddiness - vertigo

Faintness : Do you ever feel faint

HEAD : Do you get headaches

EYES & VISION :

EARS & Sense of hearing :

NOSE & Sense of smell :

FACE & Facial expression :

MOUTH & Sense of taste :

About LIPS, MOUTH, TONGUE etc. :

TEETH, GUMS, e.g. carious teeth, bleeding gums

LIPS : Cracked, peeling of skin etc

THROAT ( including tonsils ) :

Any difficulty in swallowing :

Any trouble in BACK, LIMBS or JOINTS :

Any abnormality, swelling, numbness, paralysis :

SKIN : itching, eruptions ulcers, warts, corns, peeling

STOOL

Do you have any problem regarding your stools

When and how many times a day you pass stools

When is it urgent

Do you have any problem about bowel movements

Do you have to strain for stool? Even if soft

Do you have belching or passing gas ? Describe its character

How do you feel after passing gas up or down

URINATION & URINE

Any problem about urine

Any strong smell Like what

Do you have any trouble before, during and after passing urine

Any difficulty about the flow? Slow to start, interrupted, feeble, dribbling etc.

Any involuntary urination ? When

SWEAT / PERSPIRATION - FEVER - CHILL

How much do you sweat

Where and on what part do you sweat most

Do you perspire on the palms or soles

Is the sweat warm, cold, clammy, sticky, musty, greasy, stiffens the linen etc.

What is the smell like ? e.g. foul, pungent, sour, ruinous

What color does it stain the clothing

Is the stain easy to wash off or difficult

Any symptoms after sweating

When do you get fever or chill

Do you experience any sense of heat or cold in any part of your body

Do you have burning or heat in your palms or soles

CHEST - HEAT - COLD - COUGH

Do you catch cold often ? If so, how

Describe the symptoms, nature of discharge etc

Is there any trouble with your CHEST or HEART

Is there any trouble with your voice or speech

Is there any difficulty in breathing -

Do you have cough Is it more at any particular time

SEXUAL SPHERE ( GENERAL )

Any excessive indulgence in sex in past and present

Any effect on your health

How do you feel after sexual intercourse

Any particular feeling or symptoms appear before, during or after sexual intercourse

Do you suffer from any sexual disturbance

Any habit like (masturbation etc.) in past or present ? How often

Any homosexual inclination

Did you suffer from any sexually transmitted disease

Syphilis ? Gonorrhea ? Herpes ? HIV ?

Did you have increased desire or decreased desire for sex

Did you have increased desire or decreased desire for sex

What is the method you use for family planning (contraception)

Gender

Male Female

Questions For Men

Any difficulty in erection

Wanted erection ? Unwanted erection

Weak erection ? Failing erection? Describe

Any other trouble in sex ? Describe in details

Questions For Women

Menses : How are the periods; regular or irregular

At what age did you start

Was there any trouble then

Mention interval between two periods

Mention number of days of flow

Menstrual flow: Is there any change now in quantity

Color, smell or consistency

Are the stains difficult to wash

Have you noticed any variation in quality and quantity of flow during menses

Do you suffer in any way before, during or after menses

What symptoms did you suffer during menopause

Is there any white discharge

If so, mention the nature, color, consistency and smell of discharge

Has the discharge any relation to menses

What is the effect of this discharge on your general feeling? Or any of your symptoms

Any itching, excoriation etc. due to discharge

Any trouble with breasts

CONSENT FORM FOR HOMEOPATHIC ASSESSMENT and TREATMENT

Patient Name

File No

Registrant Name

Registration Number

ASSESSMENT and RECOMMENDED TREATMENT (including those by referral to another practitioner)

I, the undersigned, do hereby acknowledge that I have been informed of and understand the assessment and recommended treatment described above and have discussed to my satisfaction this and any requests for related information with the Homeopath named above. I have been given the opportunity to ask questions about the assessment and recommended treatment and have received answers to such questions. I further acknowledge and confirm that I have been informed of, and understand the procedure(s) with respect to the nature of the procedure, expected benefits, material risks, material side effects and financial cost; the likely consequences of not having the procedure(s), and what alternative course(s) of action are available to me. I understand that I can withdraw my consent at any time.
As a result, I do hereby voluntarily provide my informed consent for the recommended treatment specified above.

Patient or Lawful Representative Signature

Date Signed

Witness Signature*

Relation to Patient

Address

Phone No.

*Witness signature is advised but not required

REFUSAL OF CONSENT

I understand that I can withdraw my refusal of consent.

I also understand that my refusal of the above consent is contrary to the recommendations of my Homeopath. As a result, I do hereby voluntarily and on an informed basis refuse consent for the recommended procedure(s) specified above.

Patient or Lawful Representative Signature

Date Signed

Witness Signature*

Relation to Patient

Address

Phone No.

*Witness signature is advised but not required

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