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SNEHAM Clinic Questionnaire
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1. Name and Age of the Patient
Your answer
2. Contact number (Whatsapp supported) and Email Id
Your answer
3. Who referred you to consult SNEHAM?
Social Media
Friend or Relative
Word of Mouth
Other:
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4. What is your chief complaint for which you want to seek treatment ? Since how long do you have this complaint?
Eg: Headache since 2 years
Your answer
5. What are the other complaints along with the chief complaint? Write each complaint is since how long.
Your answer
6. Any Past history- Chronic illness/Surgery?
Eg: Malaria/Jaundice/ Any surgery, etc
Your answer
7. Any Family History? (Mother, father, Siblings)
Your answer
8. What other modes of treatment have you tried before this? (Eg- Allopathy/Ayurveda, etc)
Your answer
9. What medications are you currently on and their dosages?
Eg: For BP- Telma
Your answer
10. What investigations (Blood reports, Imaging tests, etc) have been done till now? Please email the reports to
snehamdigitalclinic@gmail.com
Eg: CBC, X-Ray, MRI, etc
Your answer
11. What could be the cause of your complaints according to you?
Eg: Stress, Any previous infection, etc
Your answer
12. Do You follow any diet or exercise regime regularly?
Your answer
13. Who is that one person who can describe you well?
Your answer
14. Do you give the consent to be treated with Homoeopathy in Clinic or on the Digital medium (Telephonic/ Video call consultation)?
Yes
No
Maybe
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