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Please fill up this form now and submit. This is a necessary requirement for your healing protocol.

Case History Information Form

All responses submitted are kept strictly confidential with Dr. Andrew Dutta only.

While responding, please take your time to think carefully, recall your memory and respond very honestly.

 

Your honest and open response will enable Dr. Andrew Dutta to make proper healing protocol for you.

1) In a week, every morning when you wake up from sleep, how often you feel tired, fatigued and lack of energy?
2) In a week, everyday in your waking hours, how often do you feel down, sad, lonely or depressed?
3) In a week, everyday in your waking hours, how often you feel drastic changes to your moods suddenly?
4) How often do you feel that there is an inner voice speaking to you in your head?
6) How frequently you drink alcohol such as wine, whisky, rum or vodka in a week?
7) How frequently you take psychedelic drugs or recreational drugs like LSD, marijuana, ketamine, weeds or grass in a week?
8) In the past 6 months to one year, how often do you think that you have taken decisions or acted suddenly or erratically on your impulses?
9) In the past 6 months to one year, how often did you feel very forgetful or loss of memory or could not remember a few hours or days in a week?
10) Do you read religious texts?
11) Do you feel any discomfort while reading the religious text?
12) When you laugh, you love to laugh very loudly?
13) In the past, have you undergone any surgery by being made unconscious with anesthesia?
14) In the past, have you been hit hard on your head and fell unconscious?
15) In the past, have you ever blacked out or fell unconscious after heavy alcohol drinking?
16) In the past, have you ever met with a serious accident and fell unconscious?

Thanks for submitting!

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