CCRH Survey for Prophylactic Homoeopathy for Influenza-Like Illness
This survey is designed by the Epidemic Cell, CCRH to primarily assess whether individuals have developed any symptoms after taking prophylactic homoeopathic medicine. This information will help us in formulating the future strategy for homeoprophylaxis. Due to COVID-19, there is lockdown and it may not be possible to collect information personally, therefore persons are being requested to fill this form.
All of the information shall be kept strictly confidential and the data will be analyzed at group level without revealing the identity of any individual participant. By responding to this questionnaire, you are agreeing to participate in this survey willingly and permit CCRH to utilize its outcomes in the form of publications and for policy development.
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Q 1. Date of filling the form *
MM
/
DD
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YYYY
Q 2. Full Name
Q 3. Age *
Q 4. Gender *
Q 5. Your Email ID
Q 6. In which Indian state are you currently residing? *
Q 7. Your present residential area may be classified as - *
Q 8. Employment status *
Q 9. Educational status (Highest educational qualification) *
Q 10. Monthly Income status *
Q 11. What kind of diet do you follow? *
Q 12. How often do you smoke?
Clear selection
Q 13. How many people are living with you at your present residence? (including you) *
Q 14. Within the past 1 month, did you come in contact with an infected person suffering from symptoms of a flu-like illness? [Flu-like illness - Fever, Cough, Breathing difficulty, Sore throat, Hoarseness, Sneezing, Running nose etc.] *
Q 15.a. Please indicate within how many days you developed each of the following symptoms
Did not have this symptom
within last 15 days
between 16 days to 30 days before
Fever
Dry Cough
Cough with sputum
Blood in sputum
Breathing difficulty
Runny nose
Decreased sense of smell
Sneezing
Sore throat
Throat congestion
Ear pain
Redness in eyes
Pain in Head
Confusion
Chest pain
Nausea/vomiting
Diarrhoea
Pain in muscles or joints
Tiredness
Skin Rash
Clear selection
Q 15.b. Please indicate the severity with which you may have developed each of the following symptoms.   (Mild/Moderate-requiring some modification of activity, Severe – Requiring very major modification in daily activity)
None
Mild
Moderate
Severe
Fever
Dry Cough
Cough with sputum
Blood in sputum
Breathing difficulty
Runny nose
Decreased sense of smell
Sneezing
Sore throat
Throat congestion
Ear pain
Redness in eyes
Pain in Head
Confusion
Chest pain
Nausea/vomiting
Diarrhoea
Pain in muscles or joints
Tiredness
Skin Rash
Clear selection
Q 16. Have you already taken/started any treatment for these symptoms? (as mentioned in Q 15)
Clear selection
Q 17. If yes to Q16, please select which treatment(s) you are taking or considering (if not, kindly proceed to next query)
Q 18. Have you taken any homoeopathic drug as prophylactic against flu-like illness within the past 4 months? If YES, then please proceed to the next query. If NO, then please go to Q 26. *
Q 19. Which homoeopathic medicine(s) have you taken as prophylactic?
Q 20. When did you last take the prophylactic homoeopathic medicine(s) mentioned above?
MM
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DD
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YYYY
Q 21. For how many days did you take the homoeopathic medicine?
Clear selection
Q 22. How many times a day did you take the homoeopathic medicine?
Clear selection
Q 23. How confident are you regarding the protective effect of the homoeopathic medication taken by you?
Clear selection
Q 24. What inspired you the most in choosing homoeopathic medicine as a prophylactic?
Q 25. From where did you obtain the prophylactic homoeopathic medicine?
Q 26. Are you suffering from any of the following? *
Required
Thank you for your valuable time!
Epidemic Cell, CCRH
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