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 www.dramitkarkare.com 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 | swaroopclinic@gmail.com

Please note:
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)
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Email *
Who is filling this questionnaire ? *
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 ? *
Required
Name of the Patient *
Date of Birth *
MM
/
DD
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YYYY
Education *
Work status *
Required
Occupation - Designation *
Family members - details *
Postal Address *
Contact numbers ( patient as well as care-takers ) *
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