Addiction Questionnaire - Dr Amit Karkare
Thank you for reaching Swaroop Clinic for de-addiction treatment programme.
TOGETHER WE CAN OVERCOME ANY OBSTACLE IF WE PUT RIGHT EFFORTS AND TAKE CARE OF THE OBSTACLES TO CURE. WE WILL DO IT... SINCE WE HAVE TO DO IT!
We can help you to get away from the addiction with the help of behavioral modification techniques, supported by homeopathic and bach flower remedies. You can visit our website
to read a dedicated blog-post regarding this treatment programme, its objectives, methodology and outcomes.
This questionnaire wil help us to understand your individual needs and clinical state at the moment.
It will also help us to plan a personalized treatment and counselling plan for you.
Kindly be specific and elaborate all your observations about your kid, without keeping anything in reserve.
Any information can turn out to be the key for counselling as well as to find the right remedy.
A better information will ensure faster recovery. Thanks!
- Dr Amit Karkare |
We ensure adequate confidentiality about the information provided.
Medicines will be shipped from Swaroop Clinic to you.
WE DO NOT PRACTICE 'PRESCRIPTION ONLY' CONSULTATION
WE DO NOT DISCUSS MEDICINE DETAILS WITH PATIENTS.
FEE-STRUCTURE (specifically for the de-addiction programme)
First consultation: Rs 3000 (First case history session and one month medicine)
Follow up: Rs 2000 (one session and one month medicines)
Sign in to Google
to save your progress.
Who is filling this questionnaire ?
Patient himself / herself
A friend or family member or a well-wisher
Addiction is a psychological and physical inability to stop consuming a chemical, drug, activity, or substance, even though it is causing psychological and physical harm. What are you addicted to ?
How will you describe the current state ?
I really want to quit it at any cost and I am ready to do anything
I have tried a lot, I do quit for some days or months but I slip back
I have tried but not with much sincerity
I have just been thinking about it, never given any try
NO! there is ZERO willingness - in fact, a strong denial to quit, although it's much needed
Name of the Patient
Date of Birth
Lost the job(s)
Occupation - Designation
Family members - details
Contact numbers ( patient as well as care-takers )
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service