Patient Form – Ruqyah Service USA

Javascript is disabled

Javascript is disabled on your browser. Please enable it in order to use this form.

Ruqyah Service has designed the Patient Health Assessment form to gather crucial information from the patients seeking Ruqyah. Information provided will be reviewed by the Raqi to assess your condition. Complete the assessment form & submit to initiate request for Ruqyah Service.

This form will require approx. 20 to 30 mins to complete. DO NOT REFRESH the page as you may lose filled in content. You may use the “Next” or “Previous” button to go back & forth. This form will not be saved until you click “Submit”.

IMPORTANT NOTICE:

Ruqyah Service is neither a healthcare provider nor is it qualified to provide any medical advice. It is important that you be examined by a medical doctor to confirm that you do not have a medical condition that can be diagnosed and treated by common medicine.

Check this box to confirm that you have read and agree to the above statement.

Identification

Write here

your@email.com

212-111-2345

City*

ex. San Francisco

State

ex. CA

Age

Marital status

Gender*

Part A : Background

Q.A1) Why are you seeking Ruqyah?

Write here

Q.A2) When did the symptoms start?

Write here

Q.A3) Have you been diagnosed by a professional doctor, health care provider ? Are you under a medical treatment plan ? Please provide details.

Write here

Q.A4) Have you seen a spiritual healer / Raqi ? What was the diagnoses / treatment provided ?

Write here

Q.A5) Have you done Self Ruqyah ? If yes, After completing self ruqyah, What did you feel ? Briefly describe your symptoms.

Write here

Q.A6) Do you wear / have amulets (taweez), charms ? Or have talisman at home for good luck, prosperity, protection, etc?

YES

Q.A7) Have you or member of your family on your behalf offered animals for sacrifice involved with occult practice ?

YES

NOT SURE

Q.A8) Are you or member of your family involved with spiritual occult practices ?

YES

NOT SURE

Q.A9) Is any of your family member afflicted / diagnosed with magic / Jinn posession ?

YES

NOT SURE

Part B : Faith & Practice

Q.B1) Do you govern the five daily prayers?

YES

Q.B2) Do you recite Quran everyday?

YES

Q.B3) Do you recite your morning & Evening Azkar?

YES

Q.B4) Do you dislike water/ making ablution for prayer?

YES

Q.B5) Do you dislike hearing to Azan / Quran?

YES

Q.B6) When listening to Quran, do you feel uncomfortable, something moving in body, throat, stomach, feel like crying / tremble and want to stop listening ?

YES

Q.B7) Do you avoid acts of worship and obedience, remembrance of Allah and reading the Quran?

YES

Q.B8) Do you constantly forget to say Bismillah before eating or drinking?

YES

Q.B9) Are you unable to focus in prayer?, Always in a haste to complete prayer and constantly forgetting words or how many rakah’s have been performed ?

YES

Q.B10) Do you have muscle spasm / cramp during prayer?

YES

Q.B11) Do you like listening to music?

YES

Q.B12) Are you involved in usury ( interest )?

YES

Q.B13) Are you involved in any major sin?

YES

Part C : Psychological (During Day/Work Time)

Q.C1) Feeling

Check all symptoms that apply.

Intense fear

Someone always watching

Presence of someone around / in house

Hopelessness

Q.C2) Mental

Check all symptoms that apply.

Personality disorder

Hallucinations (hearing voices, seeing unreal images)

Communicating with imaginary people

Absentmindedness

Hear someone talking

Shadows moving around / extreme forgetfullness

Q.C3) Nervous

Check all symptoms that apply.

Delusion , depression & suicidal thoughts ( feeling ugly )

Anxiety

Tension & Irritability

Epilepsy ( sudden unconsciousness)

Waswas (whisperings)

Psychological (During Night/Sleep Time)

Q.C4) Sleeplessness / Insomnia

YES

Q.C5) Dreams & Sleep

Check all symptoms the apply.

Scary dreams / nightmares

Self falling from height , drowning in water or flying

Grave, graveyard

Filth, self around filth or fitly or smell filth.

Unusual people or in unusual condition, forms long, black, fearful, deformed.

Self ( dead, dying or Among Dead )

Erotic , wet dreams

Fire ( around, burning, rain, balls )

During sleep making noises ( talking / moaning / groaning / loud snoring )

Anxiety - Etreme fear on waking up

Feeling - Sleep Paralysis

Hearing - unrecognizable voices during sleep.

Dream animals being around, in house or chased Black (Cat, Dog, Snake) etc.

Part D : Physiological

Check all sysmptoms not associated with any medical cause.

Q.D2) Feeling

Check all symptoms that apply.

Something moving in body

Numbness ( Hand / Feet)

Nausea, Dizziness, Vomiting

Heaviness on shoulders / back

Sudden pressure in ear

Q.D1) Pain

Check all symptoms that apply.

Pain / bruised (blue) spots in parts of body

Lower back, Shoulders , Shoulder blades, Head, Stomach, Womb

Moving Pain ( Head, Neck, Shoulder)

Stomach ( Cramps, Bloating, Gas, Heat, Acidity )

Tightness in chest , Heart

Constriction in throat

Pins & needles in body

Headache ( constant, no medical cause)

Muscle spasm

Q.D3) General

Check all symptoms that apply.

Seizures

Paralysis ( Complete / Specific part of body )

Senses - Bad smell from mouth, body even after shower

Sudden / abnormal change in health

Senses - Sudden Loss / weakness in vision

Constant burping

Abnormal hair loss

Sexual - (M) Impotency / PE

Sexual - (F) Continous (Bleeding, Infertility, Infections, Miscarriage)

Skin - continuous ( Rashes, pimples (pink/yellow) at random spots )

Part E : Relational & Behaviour

Q.E1) Check all symptoms the apply.

Part of body shakes

Urge/Desires - To sleep on Stomatch

Hate people around you

Strange Staring / rapid blinking of the eyes

Always / uncontrollable Bad Temper

Loss of apetite

Sudden mood swings : Love, kindness to Hate for some one

Staying in washroom for long

Afraid in the bathroom / staying dirty- not showering

Desire seclusion

Unable to concentrate

Constant negative thoughts

Extremely / Always Suspicious

Frequent visit to toilet / Urination

Always sleepy during day

Talking to self

Abnormal appetite ( excessive / miniscule)

Extreme laziness, weakness

Compelled to say/do things beyond control

Sudden obedience or love for person

Urge/Desires - To flirt with opposite sex (non mahram)

Erratic / destructive behavior in one's words and actions causing enemity between people, destroying things etc)

Q.E2) Addiction

Masturbation

Visiting promiscuous (pornographic) websites developing an overwhelming urge to do so.

Smoking

Drinking

During Night/Sleep Time

Q.E3) Check all symptoms the apply

Sweating While Sleeping

Laughing/crying /suffocating in sleep

Mincing Teeth

Sleep Walking

For Married - Behaviour with Spouse

Q.E4) Check all symptoms the apply.

A sudden change in attitude from love to hate towards spouse

Exaggerating the causes of disputes for trivial matters

Changing mental image of your spouse to undesirable / ugly

Spuse hates anything the partner does and is constantly irritated by them.

Lack of Sexual Desire

Hate everything about spouse/ failed marriages

Unable to have intercourse with spouse

Unable to reproduce / conceive

Spouse hates his/her partner when in close proximity, and desires to be close when apart

Part F : Material Affairs

Q.F1) Do you experience constant blockages in your affairs?

e.g: Difficutly in education, Job, Marriage, Children. Unexplainable & Constant failures / losses in business dealings / material posessions etc..

Part G : Details

Q.G1) For the symptoms marked in previous sections, Please describe in detail.

Write here

Q.G2) What is the frequency of the symptoms?

( Rare / Sudden / Extensive / Long duration )

Q.G3) What makes the symtoms pain worst / intolerable or better?

Write here

By submitting this form, you hereby agree to accept our Terms & Conditions.

Your form has been submitted

Thank you for submitting the form. Proceed to schedule a consultation appointment to review your submission with Ruqyah Service Team.

To book an appointment:
(1) Go to Booking Calendar page.
(2) Read instructions and submit appointment request.

Thank You,

If you have any questions you may reach us through : support@ruqyahservice.com

RuqyahService.com – Team

Go back to Home Page

Server Side Error

We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.

If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.

TextStatus: undefined
HTTP Error: undefined

Processing you request

Error

Some error has occured.