Survey: Flu like acute illness
Dear sir/madam, We are conducting survey of patients who are under Homoeopathic treatment since last 6 months. Patient is supposed to be responding to this survey. We would like to explore how often you have suffered from influenza like illness and what has been the over all impact on your immunity during this phase. We would also try to understand your state of health during this covid-19 pandemic. Your personal information will remain confidential. We request you to participate in this survey. This link is sent to you by your Homoeopathic doctor. This form comes to you from Research department of Spandan holistic Institute of Applied Homoeopathy. The study is being carried out in collaboration with various Homoeopathic physicians and organizations. We sincerely request you to cooperate by filling up this form.
प्रिय महोदय / महोदया,
हम उन रोगियों का सर्वेक्षण कर रहे हैं जो पिछले 6 महीनों से होम्योपैथिक उपचार कर रहे हैं। हम इस बात का पता लगाना चाहते हैं कि आप कितनी बार इन्फ्लूएंजा जैसी बीमारी से पीड़ित हो चुके हैं और इस चरण के दौरान आपकी रोग प्रतिरोधक शक्ति पर क्या प्रभाव पड़ा है। हम इस कोविद -19 महामारी के दौरान आपके स्वास्थ्य की स्थिति को समझने का भी प्रयास करेंगे। आपकी व्यक्तिगत जानकारी गोपनीय रहेगी। हम आपसे इस सर्वेक्षण में भाग लेने का अनुरोध करते हैं। यह लिंक आपको अपने होमियोपैथिक चिकित्सक द्वारा भेजा जाता है। यह प्रपत्र स्पंदन हॉलिस्टिक इंस्टीट्यूट ऑफ एप्लाइड होम्योपैथी के अनुसंधान विभाग से आता है। विभिन्न होम्योपैथिक चिकित्सकों और संगठनों के सहयोग से अध्ययन किया जा रहा है। हम आपसे अनुरोध करते हैं कि आप इस फॉर्म को भरकर सहयोग करें।
यदि आपका कोई प्रश्न है तो आप  पूछने के लिए आपका स्वागत  हैं     info@spandan.co

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 First Name *
Middle Name
Last Name *
Sex *
Age in years *
In which state you reside?
Name of district
Your Physician's Name *
Date of Filling up the form *
MM
/
DD
/
YYYY
Your E mail id
Mobile number *
Since how long you have been taking homoeopathic treatment: months or years *
How often did you suffer from any of the following symptoms in last 6 months when you were under Homoeopathic treatment? *
once
Twice
Thrice or more
zero
Fever
cold and cough
chills
throat pain
Breathlessness
chest pain
How was the response to those episodes *
very good
good
Fair
Bad
Not applicable
First episode
second episode
Third and other episodes
Not applicable
Are you suffering from any of the following illness
Yes
No
Diabetis mellitus
Essential Hypertension
Any other cardiac disorders
Kidney disease
Liver Disease
Any other immunocompromising disorders
Clear selection
Are you experiencing weakness and fatigue in last 2 months. *
Any history of foreign trip in last 6 months? *
Any history of coming in contact with COVID-19 positive person? *
Have you stayed in containment area? *
Have you ever been investigated for COVID-19 *
If yes, what was the outcome *
Any other remark
Submit
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