Your Name (required)

Your Phone (required)

Your Email (required)

Your Age (required)

Your Gender (required)
MaleFemaleOther

Your Occupation (required)

Your Type Of Works (required)

Your Working Hours (required)

Appointment Type (required)
Alcoholic
YesNo

Smoker (required)
YesNo

MEDICAL HISTORY

Abnormal Weight: (required)
YesNo

Asthma: (required)
YesNo

Diabetes Mellitus: (required)
YesNo

Hypertension: (required)
YesNo

Neurological Deficit: (required)
YesNo

Hormonal Abnormalities: (required)
YesNo

Cancer: (required)
YesNo

Renal Disease: (required)
YesNo

Cardiac Disease: (required)
YesNo

Psychiatric Disease: (required)
YesNo

PRESENTING COMPLAINTS

Taking Which Type of Addition? (required)

How Much Quantity at Present: (required)

For How Long Taking This Addition Initially What Quantity: (required)

Dose You Take: Alone (required)

Dose You Take: With Friends (required)

And What Time You Start Taking Alcohol or Drugs: (required)

If You Not Taken the Alcohol or Drugs What Happens: (required)
Loss of appetiteLoose MotionBody AcheUnable to SleepWrong Thought

You are Interested to Leave the Alcohol or Drugs: (required)
YourselfWifeChildrenparentsfriends

Have you try to Leave Alcohol or Drugs?: (required)
YesNo

What Was Success in leaving the Drugs? (required)
Short TimeLong Time

How much time you Left the Alcohol or Drugs:(required)
1 Month3 Month6 Month1 Year

After Leaving the Alcohol or Drugs How you feel:(required)
GoodBettersatisfactoryNot Good

What was Reaction of your close person after leaving the Alcohol or Drugs? (required)
They AppreciableDo Not Appreciable