REGISTRATION full name Date of birth Gender MaleFemaleOther Home Language PunjabiHindiEnglishOther Home Address occupation Mid SchoolSenior Secondary SchoolGraduatePost-GraduateDoctoratenone of the above Do you often drink/use for a few days continuously? YESNO Do you feel shaky or sick in the morning after drinking/using the previous night? YESNO Do you sometimes have loss of memory? YESNO For how long have you had an addiction problem? YESNO Are you willing to, on a voluntary basis, do the full treatment programme at Ramot? YESNO [cf7sr-simple-recaptcha]
