Online Treatment or Correspondence Treatment
Only in special cases , Correspondence treatment is given. Know your Patient - Questionnaire is supplied by the Sukhsagar Medical College to be answered /replied by patient. Only administrative Monthly fee charges are applicable. All letters are replied during this period The format of Questionnaire is given bellow.
Questionnaire
You can download questionnaire form from the link mentioned below and send it to the following address :-
The Director,
SMCRC,
799/2 Patel nagar
New Mandi Muzaffarnagar
250001 (U. P.) INIDA.
- Patient’s Name: _______________________________________________________________
- Patient’s FullAddress: __________________________________________________________
__________________________________________________________
- Patient’s t Age & Education: _______________________________________________________
- Height & Weight:
At present Before Disease
Height: _____________ Height: _____________
Weight: _____________ Weight: _____________
- Married or unmarried: ____________________________________________________
- Occupation - Its duty hours? How spent - Sitting Deskwork or Movement field work?
___________________________________________________________________________
- Period of rest, sleeping time at night and rising time in the morning. Quality of sleep -
deep or disturbed: ____________________________________________________________
- What and how much do you eat; at what time do you eat? ______________________
___________________________________________________________________________
- Number of times bowels are cleared? Type - Solid or loose? ____________________
- Do you suffer from constipation? Are their itching, boils, rashes on the body? ___________________________________________________________________________
11.Taste of mouth, colour of tongue: __________________________________________ __________________________________________________________________________
- Any addiction - Biri, Cigarette, Tobacco, sniffing/orally, Ganja, Opium, alcohol, Betel- leaves, Betelnuts, Smack/hashis etc.: ____________________________________________________________________________________
- Mental status - worries free or worry some: ________________________________________________________________________________________________________________________________________________________________________
- History of the case from beginning: ______________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________
- Diagnosis by Doctors: ___________________________________________________
________________________________________________________________________
_______________________________________________________________________________
- Is illness permanent or intermittent? ____________________________________________
- Present symptoms of diseases: ________________________________________________
- Hereditary disease in your family: ______________________________________________
- If fever - when and how much: _________________________________________________
- Eye sight - week or strong; spectacles used, its power: ____________________________
- Dental condition: _____________________________________________________________
- Do you perform Worship, prayer or meditation: ___________________________________
- Have you gone through nature-cure; name the books: _____________________________
_______________________________________________________________________________
- If taken nature-cure treatment - its description: ____________________________________
________________________________________________________________________________
- Seasonal fruits/vegetables of your place: ___________________________________________
- Temperature of town/place: ________________________________________________________ ___________________________________________________________________________________
- Any other special mention: _________________________________________________________ ____________________________________________________________________________________
For Ladies use only
- Menstruation’s - timely or untimely - duration; Any unnaturality:_________________________________________________________________________
__________________________________________________________________________________
- Have suffered from leucorrhoea: ____________________________________________________
- Has or how has it been treated? _____________________________________________________
- Suffered abortion? _______________________________________________________________________________________________________________________
Space for special details if any