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Questionnaire
Order Number
Patient Name
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Email Address
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Phone Number
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Any Medical Condition:
Blockages in Life:
Don’t feel progressing in life? Life going in circles?
Can’t find work? Cant find work according to education/experience? Can’t do business?
Cant Study? Not getting grades? Can’t concentrate?
Unusual relationship with spouse, children, parents, Boss etc?
Unusual Marriage Problems? Fertility & Impotency Issues?
Cant save money! You get a big amount of money & it is spent quickly?
Unusual Health Problems:
Migraine, Headache, heaviness & weight on head, feel tired all the time.
Feeling pain : Shoulder, back, ribs, knees & stomach ache? heaviness on thighs.
Feeling needle pricks on the body or tightness in chest during night?
Irregular periods / menstruation
You are not conceiving yet there are no medical issues with you & your spouse?
You feel suffocated at night or during the day?
Feeling like being chained or continuous burping?
Constriction (narrowing) in throat
Foul smell or odour in breath while burping even after mouth wash or shower or perfume?
Eczema or psoriasis or any other skin disease doctors don’t have treatment for?
Any other physical problems with no medical cure?
Difficulty in sleeping at night? Wake up with jerks or with nightmares? Sleep paralysis
Feeling constantly tired & lethargic? Feeling uneasy restless, anxiety?
Unusual Mental State:
You are getting angry with your spouse or children with no apparent reason?
You are getting sad, depressed for no apparent reason? Sudden mood swings?
You are having doubts?
You have fear? Getting scared. You feel some one is following you? Afraid of darkness?
You forget things? You forget what you were reading in your prayers? No of rakats etc.
You say something but people don’t understand you?
You are hallucinating things or hearing strange noises in your ears? Some one following you?
Lack of concentration?
Sudden feeling of love or hatred towards a particular individual?
Sudden change in character, feeling aggressive or want to be isolated or talking to oneself?
Sudden loss of interest in prayers & religion? Laziness in reading Quran, zikr & salat?
Sudden interest in bad things – alcohol, smoking, drugs, pornography & sex?
Madness? Some one is touching you? Scared of looking in the mirror?
Your Home looks dark & scary?
Unusual Dreams & Other Issues:
Dreaming to be chased , having fights in dreams, blocked or imprisoned; obsticles everything you do, circles.
Dreaming snakes: Life is blocked to earn, marry, study, conceive babies; if husband wife discuss things they end up fighting/arguying
Dreaming a mass of water, river, Tsunami, flood
Dreaming climbing, falling, flying or in an airoplane thinking, being somewhere high- away from reality, life going round in round in circles
Dreaming about a hole, bridge or well, falling in a deep place; deep problem, permanently losing money
Dreaming dead people, graves or funerals. Apathy, depression, weakness and thinking about death
Dreaming about vehicles, journey, travels, mounts, foot illness.
Dreaming children or babies. Bad effect wrapping the person, cant conceive
Alteration of the personality, ugliness, darkness of the face, medical problems related to face and skin
Worries, anxiety, successive problems, headaches, mental problems
Dreaming about people, study problems, concentration problems, memory problems
You are having Sadness, anxiety, depression - dark aspect, bad perception
Dreaming of fire, embers or smoke; burning in the body, accidental burns in real life.
You feel being tired, promises not honored, extremely complex situation
If you have blockages in Life, bad luck in everything you do
Used in sorcery like doll to burn or cut or sting, Broken chance
You get Stinging sensation, multiple pains in the body
Getting angry with no apparent reasons
You have any kind of Blood illness, abnormal health problems
Dreaming blood, having irregular periods, sexual and pregnancy problems
If you have Resistant illnesses, miserable or repulsing look, sickly complexion
Dreaming dogs, experiencing deteriorating of the character in real life
Dreaming fish or fishing
Bone illness, pain or weakness in the bones
Dreaming excrements, shitting, dirty water or toilets
If you have a skin illness like Eczema or psoriasis etc
Evident stupidity/foolishness, unable to understand, or become stubborn
If you are getting heavy erotic dreams – lover jinns
If you are getting heavy erotic dreams – impotency, not attracted to spouse
If you feel burning sensationlike hot pimento, constant nervousness, anxious
If you are dreaming crazy people. If you think you are loosing mental capacity on different degrees
Dreaming meat, soul captured (no personality, sorcery with sacrifices
Difficulty to think or decide loss of confidence
Dead personality, no conscience. Any part of the person dead, not responding any more
If you are Loosing Money. The money comes and gets spent quickly does not stay.
If you dream people or creatures with Masks
If you hear NOISES, VOICES OR BUZZING
If you feel Jinn’s PRESENCE IN THE HOUSE
If you are addicted to Alcohol, smoking, gambling, adultery, drugs etc or any other PASSION
If you have a MENTAL WEAKNESS
If you have an EYE DISEASE
If you have STERILITY AND SEXUAL WEAKNESS
If you feel COLD
Dream about Termites, ants, insects, spiders etc. You will feel pricking in your body like you have pins inside
If you are scared, scared of darkness, your house looks gloomy
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