Cost of Treatment

 Name of the Patient: -

 CRF NO: -
 Age: -
 Sex: -
 Education: –
 Diagnosis: -
 Duration of Illness:-
 Duration of Treatment:-
 Monthly Income Cost
Sr. Particular 1st 2nd 3rd Total
No Month OF month month
cost of cost of cost

1 Total monthly cost on Medication

2 Total weekly cost on Medication (All-inclusive):

3 Total consultation charge

4 Frequency of visit Weekly Monthly 3- Total

month
5 Visit to whom: Psychiatrist/ Physician/
Neurologist/ Others

6 Investigation Charges:
(EEG, CT-SCAN, MRI, ELISA)