Adult Intake Form — H2O Clinic Homeopathy

Let's start with the basics

This takes about 30–40 minutes. Your answers save in this browser as you go, so you can stop and come back.

Contact details

Full name *

Please enter your full name.

Street address *

Please enter your address.

City *

Please enter your city.

Province *

Please select your province.

Postal code *

Use the format A1A 1A1.

Occupation

Marital status

Home phone

Cell phone *

Enter a phone number with at least 10 digits.

Email *

Enter a valid email, like name@example.com.

Date of birth *

Enter a date of birth in the past.

Age

Sex *

Please select an option.

Referred by

Illnesses you've had

Every illness, medicine or accident leaves a mark. Knowing your history helps us treat the whole picture, not just today's symptom. Tap anything you've had — then add the details below.

Select all that apply

Details of each illness

IllnessAgeDurationRecovered?Treatment taken

Medicines, tonics and stimulants

Anything you've taken at any point in life

Anything else about your past health

Your family's health

Patterns run through families. Fill in what you know — approximate answers are fine, and blanks are fine too.

Parents and grandparents

RelationAlive / DiedAgeIllnessesCause of death

Extended family

Has any relative had trouble similar to yours?

Brothers and sisters

Include any who have died. Mark your own row by typing "Self" in the name field.

NameAlive / DiedAgeIllnesses

Your early life

If you don't know, write "unknown" — that's a useful answer too.

Birth

Did your mother have any problem during pregnancy?

Did she take any drugs during pregnancy? Which?

Was there any difficulty with your birth?

Milestones — at what age did you start?

Urine control / bed-wetting

Eating indigestibles — chalk, lime, earth, slate-pencil

Any other problem with growth or development

Animal bites

If any, in what order?

Did you take anti-rabies, anti-venom or other treatment?

Vaccinations — number of times

Any reaction or trouble after a vaccination?

Household and habits

Family now

If married — how is your spouse's health?

Children — living and deceased. If deceased, state the cause under illnesses.

NameSexAgeIllnesses suffered

Any abortions, miscarriages or stillbirths?

Habits

There's no judgement here — accuracy helps us prescribe well.

What brings you here

This is the heart of the form. Be as specific as you can: where it is, exactly what it feels like in your own words, when it started, and what makes it better or worse.

Main complaints and history

Describe your complaints, the onset and the course, with dates *

Please describe what brings you here.

Origin of cause

Can you trace this to a circumstance, accident, illness or mental upset?

For example: shock, worry, errors in diet, overexertion, overexposure to cold or heat.

Complaint by complaint

Add a row for each separate trouble.

Where is itWhat exactly do you feelBetter / worse from

Mark the locations

Draw on the figure where your trouble sits. Use the label field to name the sensation.

Sensations at those spots

Appetite, thirst and digestion

Appetite and thirst

How is your appetite?

When are you hungry?

How fast do you eat?

What happens if you stay hungry for long?

How much thirst do you have?

Any particular time you're thirsty?

Any change in taste or feeling in your mouth?

Foods

Disagrees means it makes you unwell, whether or not you like it. Leave blank if it's neutral.

Food	Like	Dislike	Disagrees

Any other food you crave?

Stool

Any problem with your stool?

When and how many times a day?

When is it urgent?

Any problem with bowel movements?

Do you strain, even when soft?

Belching or passing gas — describe its character, and how you feel afterwards

Urine

Any problem with urine?

Any strong smell? Like what?

Body and sensations

Perspiration, heat and cold

Do you perspire on palms or soles?

Is the sweat warm, cold, clammy, sticky, musty, greasy?

What is the smell like — foul, pungent, sour?

What colour does it stain clothing? Easy or hard to wash?

Any symptoms after sweating?

When do you get fever or chill? What brings it on?

Any sense of heat or cold in a part of the body?

Burning or heat in palms or soles?

Chest, cough and breathing

Do you catch cold often? How? Describe the symptoms and any discharge

Any trouble with chest or heart?

Any trouble with voice or speech?

Any difficulty breathing?

Do you have a cough? More at any particular time?

Head and senses

Back, limbs, skin, hair and nails

Trouble in back, limbs or joints — describe in detail

Do the pains shift? In what direction do they extend?

Any swelling, numbness or paralysis anywhere?

Skin — itching, eruptions, ulcers, warts, corns, peeling. Describe its nature

Any change in skin colour, or spots?

Any abnormality of the nails or skin around them?

Hair — falling, greying, dandruff, dryness, oiliness, unusual growth

Do wounds heal slowly? Form keloid or pus?

Any tendency to bleed?

Are your troubles one-sided? Which side? Do they alternate or shift?

Any trembling? When?

Any sense of weakness? Where, and when is it more or less?

Sexual health

Everything here stays confidential and is used only to find your remedy. Answer what you're comfortable with — you can leave any question blank, or raise it in person instead.

General

Any excessive indulgence, past or present? Any effect on your health?

How do you feel after intercourse?

Any feeling or symptom before, during or after intercourse?

Do you suffer from any sexual disturbance?

Any habit such as masturbation, past or present? How often?

Any homosexual inclination?

Any sexually transmitted disease — syphilis, gonorrhea, HIV?

Has your desire increased or decreased?

What method do you use for contraception?

What makes you better or worse

This section matters most. Don't rush it. For each factor, write how it affects you — especially your main complaint. If sun gives you a headache, write "headache" next to Sun. If a factor makes you worse in one way and better in another, say both. Leave the rest blank.

Factors

Mind, sleep and dreams

Your mind has a great influence on your body. Answer freely, frankly and completely — this is what shapes the remedy.

Feelings and temperament

Sleep

Your posture in sleep — back, side, abdomen?

Any position you can't sleep in?

During sleep, do you snore, grind teeth, dribble saliva, sweat, keep eyes or mouth open, walk, talk, moan, weep, become restless, or wake with a jerk?

Anything else unusual — sleepiness, sleeplessness

How much do you cover?

Do you have to uncover any parts?

Dreams

Select every kind of dream you have.

Any other dreams — describe

You as a child

Tap once if it was true of you. Tap again for "strongly".

Did your mother suffer physical or emotional stress during pregnancy? What did she dream?

Anything else striking about you as a child

Describe one incident from childhood when you were very upset

Generals

Draw something

Whatever comes to mind right now, or a favourite drawing. There's no wrong answer.

✓

Thank you — your form is with us

Mahnaz will review it before your appointment. If anything needs clarifying, we'll be in touch at the email you gave us.

Let's start with the basics

Contact details

Illnesses you've had

Select all that apply

Details of each illness

Medicines, tonics and stimulants

Your family's health

Parents and grandparents

Extended family

Brothers and sisters

Your early life

Birth

Milestones — at what age did you start?

Animal bites

Vaccinations — number of times

Household and habits

Family now

Habits

What brings you here

Main complaints and history

Origin of cause

Complaint by complaint

Mark the locations

Appetite, thirst and digestion

Appetite and thirst

Foods

Stool

Urine

Body and sensations

Perspiration, heat and cold

Chest, cough and breathing

Head and senses

Back, limbs, skin, hair and nails

Sexual health

General

For men

For women — menses

For women — discharge and breast

What makes you better or worse

Factors

Mind, sleep and dreams

Feelings and temperament

Sleep

Dreams

You as a child

Generals

Draw something

Consent for homeopathic treatment

Thank you — your form is with us