INDIAN HOMOEOPATHIC RESEARCH CENTRE (IHRC)

A RESEARCH SUBSIDIARY OF IHMA CONFIDENTIAL

HOMOEOPATHIC PREVENTIVE MEDICINE FEEDBACK FORM

NAME........................................................ AGE ................. M F C ..............

ADDRESS (Residence)..............................................................................................

ADDRESS (Office School)...............................................................................................

PHONE..................................................... PINCODE.................................

1. Is there any epidemic prevalent at your residence or work place ? YES NO

2. If yes, please mark it below. If not in the list, please mention the name of the new epidemic
Viral fever, Chickenpox, Leptospirosis, Dengue, H1N1, Malaria, HFMD, Diphtheria, Japanese Encephalitis, Hepatitis
3. Do you specifically know anyone affected with the said epidemic ? YES NO

4. Please mention the number of persons for whom you are collecting the Preventive medicine.
5. Their present health status major diseases affected regular medications, if any.
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6. Are you well aware of the fact that, Homoeopathic medical system offers curative treatment for these
epidemic fevers, along with preventive medications ?. YESv NO

7. Have you been benefitted by Homoeopathic preventive medicine, earlier ? YES NO

8. For the past 5 years, how many times you have suffered from fever of any kind?
9. Were you affected by Dengue fever recently? Please mention the preventive measures taken by you?
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I ......................................................................... have collected preventive medicines for ................ persons.
I declare that, I shall make sure that the medicines will be administered as directed at the camp.

Signature v
Date................................... Namev.......................................

For official use only

Place of the camp........................................

Attending doctors.................................

No. of persons who received the preventive ...........................

Prevalent epidemic in this area.........................................

Prepared by IHRC- Research Subsidiary of Indian Homoeopathic Medical Association, Kerala State