Diseases and conditions
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It is a questionnaire used to measure an individual's overall subjective and objective health status. Please take a few minutes to answer the questions.
HEALTH SURVEY QUESTIONNAIRE
Fields indicated with an asterisk (*) are required to send this form.
Name:*
Age:*
Gender:*
Male Female
Phone:
Email:*
Write Down Your Detail Health Problems:*
(Describe your all health problems One by one elaborately and detail with the diagnosis if you have any)
Since how many days or months you have been suffering from this / these health problem? 1 to 6 month
6 months to 1 year
1 year to 2 years
2 years to 5 years
5 years to 10 years
Above 10 years
Are you under any treatment? Yes
No

If Yes, then Answer the Following Questions

What the treatments you are taking now? Allopathy
Homeopathy
Ayurveda
Herbal
Home remedies
Others
Since how many days or months you have been taking this treatment? More than 1 month, below 6 months
More than 6 months, below 1 year
More than 1 year, below 2 years
More than 2 years, below 5 years
More than 5 years, below 10 years
More than 10 years
What is the percentage of improvement after the treatment? Below 10%
Around 10 to 20%
Around 20 to 400%
Around 40 to 60%
Around 60 to 80%
Above 80%
Are you fully satisfied with the present treatment? Yes
No
No Idea
Are you worried about any drug side effects of your present treatment? Yes
No
No Idea
Have your doctor explained you in detail about your health problems? Yes
No
What is your opinion regarding the cost factor of the present treatment? Not costly make no difference
Costly
I am not concern about the cost
Do you want any treatment which is safe, free from drug side effects, effective and cure the disease not suppress? Yes
May Be
Not Decided
Do you want a treatment that not only improve your health issue but also improve your health as a whole? Yes
No
Not Decided
Have you ever tried any alternative system of therapy? Yes
No
If yes which one: Homeopathy
Aurveda
Herbal
Chiropractice
Osteopathy
Acupuncture
Energy Healing
Home Remedies
 
 
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