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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.

 

  1. Patient’s Name: _______________________________________________________________
  2. Patient’s FullAddress: __________________________________________________________

                          __________________________________________________________

  1. Patient’s t Age & Education: _______________________________________________________
  2. Height & Weight:

                                          At present                                 Before Disease      

                           Height: _____________                  Height: _____________

                           Weight: _____________                 Weight: _____________

  1. Married or unmarried: ____________________________________________________
  2. Occupation - Its duty hours? How spent - Sitting Deskwork or Movement field work?

___________________________________________________________________________

  1. Period of rest, sleeping time at night and rising time in the morning. Quality of sleep -

deep or disturbed: ____________________________________________________________

  1. What and how much do you eat; at what time do you eat? ______________________

___________________________________________________________________________

  1. Number of times bowels are cleared? Type - Solid or loose? ____________________
  2. Do you suffer from constipation? Are their itching, boils, rashes on the body? ___________________________________________________________________________

11.Taste of mouth, colour of tongue: __________________________________________ __________________________________________________________________________

  1. Any addiction - Biri, Cigarette, Tobacco, sniffing/orally, Ganja, Opium, alcohol, Betel- leaves, Betelnuts, Smack/hashis etc.: ____________________________________________________________________________________
  2. Mental status - worries free or worry some: ________________________________________________________________________________________________________________________________________________________________________
  3. History of the case from beginning: ______________________________________

________________________________________________________________________

________________________________________________________________________

_________________________________________________________________________

  1. Diagnosis by Doctors: ___________________________________________________

________________________________________________________________________

_______________________________________________________________________________

  1. Is illness permanent or intermittent? ____________________________________________
  2. Present symptoms of diseases: ________________________________________________
  3. Hereditary disease in your family: ______________________________________________
  4. If fever - when and how much: _________________________________________________
  5. Eye sight - week or strong; spectacles used, its power: ____________________________
  6. Dental condition: _____________________________________________________________
  7. Do you perform Worship, prayer or meditation: ___________________________________
  8. Have you gone through nature-cure; name the books: _____________________________

_______________________________________________________________________________

  1. If taken nature-cure treatment - its description: ____________________________________

________________________________________________________________________________

  1. Seasonal fruits/vegetables of your place: ___________________________________________
  2. Temperature of town/place: ________________________________________________________ ___________________________________________________________________________________
  3. Any other special mention: _________________________________________________________ ____________________________________________________________________________________

 

For Ladies use only

  1. Menstruation’s - timely or untimely - duration; Any unnaturality:_________________________________________________________________________

__________________________________________________________________________________

  1. Have suffered from leucorrhoea: ____________________________________________________
  2. Has or how has it been treated? _____________________________________________________
  3. Suffered abortion? _______________________________________________________________________________________________________________________

Space for special details if any