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Detecting GPS...
🏠
1. Customer & Household Survey
🏠
1. Customer / Household
🩺
2. Doctor Visit
🏪
3. Pharmacy / Retailer
Step 1 of 4: Household & Doorstep
📍 Step 1: Doorstep & Consent Gates
Gate
Are you an adult family member or authorized to provide family details?
Yes (হ্যাঁ)
No (না)
The survey purpose has been explained. Do you voluntarily agree to participate?
Yes (সম্মত)
No (অসম্মত)
Respondent / Customer Name
*
Relationship
Self (নিজে)
Spouse (স্বামী / স্ত্রী)
Parent (পিতা / মাতা)
Son / Daughter (ছেলে / মেয়ে)
Other Relative (অন্যান্য)
Number Ownership
Personal (নিজের)
Shared Family (পরিবারের)
Business / Shop (দোকান/কাজ)
Contact Mobile
*
Alt Mobile
Address Line 1 (House/Street/Para)
*
Landmark
Locality
PIN Code
Building Type
House (বাড়ি)
Flat (ফ্ল্যাট)
Basti (বস্তি)
Shop Area
Next: Family Profile ➔
👨👩👧 Step 2: Family Profile
Total Family Members
−
4
+
Age Brackets in Family (Tap all that apply)
0–17 Yrs (Children)
18–39 Yrs
40–59 Yrs
60+ Yrs (Senior)
Any family members aged 50 or above?
Yes (হ্যাঁ)
No (না)
Prefer not to say
⬅ Back
Next: Health & Needs ➔
💊 Step 3: Regular Medicines & Health Needs
Does any family member need regular medicines?
*
Yes, Regularly (হ্যাঁ)
No / None (না)
Prefer not to say
Applicable Chronic Categories (Tap to Select)
🩸 Diabetes / Sugar
💓 High BP
🦋 Thyroid
🧪 Cholesterol
❤️ Cardiac / Heart
🫁 Asthma / Breathing
🦴 Arthritis / Joint Pain
🧬 Kidney
📌 Other Long-term
How often does family buy medicines?
Every Month (প্রতি মাসে)
Every Week (প্রতি সপ্তাহে)
Every 2–3 Months
As Needed (প্রয়োজনে)
Estimated Monthly Medicine Expense Bracket
Below ₹1,000
₹1,000 – ₹2,999
₹3,000 – ₹4,999
₹5,000 – ₹9,999
₹10,000+
⬅ Back
Next: Delivery & Value ➔
🏪 Step 4: Current Habits & KLCM Delivery
Where does your family currently buy medicines?
Local Chemist (স্থানীয় দোকান)
Big Chain Pharmacy (বড় ফার্মেসি)
Online Apps (1mg / Apollo)
Hospital Counter
Interested in KLCM Genuine Home Delivery?
Highly Interested (হ্যাঁ, নিয়মিত)
As Needed (প্রয়োজনে)
Not Interested
Preferred Order Channel
💬 WhatsApp
📞 Phone Call
🏪 Store Visit
May KLCM contact you regarding doorstep delivery?
Yes (সম্মত)
No (না)
Staff Quick Notes (Optional)
⬅ Back
💾
Save & Sync Survey
Doctor & Chamber Profile
Doctor's Name
*
Doctor / Chamber Phone Number
*
Doctor ID (if known)
Chamber ID
Medical Council Registration No.
Speciality
Chamber / Clinic Name
Chamber Address & Location
Chamber Days & Timing
Person Met During Visit
Doctor
Assistant
Reception
Not Met
Doctor Discussion (10 Strategic Questions)
1. What primary patient categories visit your chamber?
2. What is the most common difficulty patients face when sourcing medicines?
3. Do patients get their prescribed medicines on time?
4. What challenges do patients face regarding stock unavailability, pricing, or supply?
5. Would a reliable doorstep medicine delivery service be beneficial for your patients?
Highly Beneficial (খুবই উপযোগী)
Beneficial (উপযোগী)
Neutral (সাধারণ)
Not Needed (প্রয়োজন নেই)
6. What service standards do you expect from an ideal pharmacy?
7. In prescription fulfillment, what matters most regarding genuine billing and exact medicine?
8. Which KLCM services would you like to receive more information about?
9. Through which channel is it most convenient to send you service updates?
10. When is the best time to contact you for future service-related questions?
Post-Visit Evaluation & Follow-Up
Doctor / Representative's key requirement
Which service can KLCM offer?
Next Action Step
Deliver Service Catalogue & Helpline
Follow-up Call with Doctor
Coordinate with Clinic Receptionist
Stock Alignment at nearest KLCM branch
Re-visit Next Week
Next Follow-up Date
Field Notes
💾
Submit Doctor Visit Report
Reset Form
Pharmacy / Retailer / Supplier Profile
Business / Medical Store Name
*
Store Address & Location
Contact Person Name
Contact Phone Number
Drug License Number
GSTIN (Optional)
Business Relationship
New Party
Existing Party
Market & Demand Dynamics
High Demand Products & Fast Moving Items
Current supply, stock or delivery bottlenecks
Issues regarding pricing, discounts or credit terms
Estimated Order Quantity / Products
Estimated Order Value (₹ Approx.)
Expected Order Placement Date
Payment / Outstanding notes (for Accounts verification)
Lead Status & Next Steps
Current Lead Status
HOT (Immediate Business Opportunity)
WARM (Interested, Follow-up Needed)
ACTIVE (Ongoing Discussions)
PENDING (Awaiting Client Decision)
COLD (No Response)
CONVERTED (Order Placed)
LOST (Opportunity Lost)
Next Action Step
Send Product Price Quotation
Collect Final Order
Payment Follow-up (Coordinate Accounts)
Re-visit Store
Next Follow-up Date
Additional Notes
💾
Submit Retailer Report
Reset Form
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Customer
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Doctor
🏪
Retailer
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