Pet Bach Remedy Questionnaire


Natural Treasure Holistic medicine
Mohamed El Siddig , NSHS, DMHS ( HD)
Homeopathic Doctor & Healer
Hypnopath/ Psychopath
Hamilton ,ON
Barton East
2892441179

Homeopathic consultation is facilitated when there is a complete picture of the individual’s mental, emotional and physical states of health.  This includes symptoms that affect both physical sensations (what does it feel like), and function (how it impacts you) and what ameliorates or aggravates each symptom.

Date

Your Name (required)

Age

Birthday

Sex

Address

City

Province

Postal Code

Phone (home)

Phone (work)

Phone (Cell)

Email

Occupation

Full-time/Part-time

Retired

Employed by

Education

Marriage Status

Depressed
 1 2 3 4 5 6 7 8 9

Demands constant attention
 1 2 3 4 5 6 7 8 9

Fearful and insecure
 1 2 3 4 5 6 7 8 9

Anxious
 1 2 3 4 5 6 7 8 9

Misses some s/he loves
 1 2 3 4 5 6 7 8 9

Skin ailment
 1 2 3 4 5 6 7 8 9

Aggression
 1 2 3 4 5 6 7 8 9

Jealousy
 1 2 3 4 5 6 7 8 9

Depressed appetite
 1 2 3 4 5 6 7 8 9

Disobedient
 1 2 3 4 5 6 7 8 9

Is unhappy traveling
 1 2 3 4 5 6 7 8 9

Suffering from physical (injury) or emotional (abandonment) trauma
 1 2 3 4 5 6 7 8 9

Name of pet

Homeopathy is considered to be an alternative/preventative system of health care and is not intended to be a substitute for allopathic or traditional medicine.

The therapy and information offered should not be construed by you, the client, or any family, friends or caregivers to be a medical diagnosis of any disease or injury.

You should consult with your physician for any serious medical condition and further, you should get at least two medical opinions for such condition.

While Mohamed El Siddig ,DHMS , DMLS , ( HD) ,CMA member has had extensive training in the science and art of Homeopathy .
I HAVE READ THE ABOVE AND AGREE TO ALL TERMS:

Signature

Do you agree?