Your Name (required)

    Your Phone (required)

    Your Email (required)

    Your Age (required)

    Your Gender (required)

    Your Occupation (required)

    Your Type Of Works (required)

    Your Working Hours (required)

    Appointment Type (required)

    Smoker (required)


    Abnormal Weight: (required)

    Asthma: (required)

    Diabetes Mellitus: (required)

    Hypertension: (required)

    Neurological Deficit: (required)

    Hormonal Abnormalities: (required)

    Cancer: (required)

    Renal Disease: (required)

    Cardiac Disease: (required)

    Psychiatric Disease: (required)


    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)

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

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

    What Was Success in leaving the Drugs? (required)

    How much time you Left the Alcohol or Drugs:(required)

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

    What was Reaction of your close person after leaving the Alcohol or Drugs? (required)



    we can help fight the stigma that surrounds these disorders and encourage and empower more people to seek the life-changing treatment they need for themselves or a loved one. We want to help people understand the facts, risks and available treatment options so that they can make informed decisions about addiction treatment and long-term recovery planning.

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