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GENERAL HEALTH AND LIFESTYLE
Your answer to the following questions will help us to understand your Dietary pattern, Lifestyle, medical history and the concerns you’d like to discuss with your doctor. Please answer all the questions below.
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* Indicates required question
Email
*
Your email
Name
*
1 point
Your answer
2.
Age
*
Your answer
3.Gender
*
Male
Female
Other:
3.Height
*
Your answer
3.Weight
*
Your answer
3.Waist Circumference (If you don’t know please write NA)
Your answer
5.
Contact No
Your answer
6.
Origin
*
RURAL
URBAN
NRI
7.
Religion
(
Optional
)
HINDU
CHRISTIAN
MUSLIM
SIKH
OTHER
Clear selection
8.
Marital Status (Optional)
SINGLE
MARRIED
DIVORCED
WIDOWED
Clear selection
9.
EDUCATION LEVEL
*
NO EDUCATION
HIGH SCHOOL
BACHELORS
MASTERS
Ph. D OR MD
10.
TYPE OF FAMILY
*
JOINT
NUCLEAR
ANY OTHER
12.
MEMBERS IN FAMILY
*
Your answer
11.
ANY FOLLOWING DISEASE (in the past)
*
HEART FAILURE
HYPERTENSION
OBESITY
THYROID
STROKE
BLEEDING DISORDERS
INFECTION
HEART SURGERY
BLOOD CLOT
HEART TRANSPLANT
HEPATITIS
ULCERS
HAEMORRHOIDS
DIABETES-I
DIABETES-II
RASHES OR SKIN PROBLEM
KIDNEY PROBLEM
BONE or JOINT DISEASE
AIDS/ HIV
HEART VALVE DISEASE
PSYCHIATRIC ILLNESS
ANKLE OR FEET SWELLING
CHEST DISCOMFORT
DIZZINESS, FAINTING, BLACKOUT
DENTAL PROBLEM
EAR PROBLEM
PCOS / PCOD
NONE OF THEM
Other:
Required
11.
PRESENT DISEASE
*
HEART FAILURE
HYPERTENSION
OBESITY
THYROID
STROKE
BLEEDING DISORDERS
INFECTION
HEART SURGERY
BLOOD CLOT
HEART TRANSPLANT
HEPATITIS
ULCERS
HAEMORRHOIDS
DIABETES-I
DIABETES-II
RASHES OR SKIN PROBLEM
KIDNEY PROBLEM
BONE or JOINT DISEASE
AIDS/ HIV
HEART VALVE DISEASE
PSYCHIATRIC ILLNESS
ANKLE OR FEET SWELLING
CHEST DISCOMFORT
DIZZINESS, FAINTING, BLACKOUT
DENTAL PROBLEM
EAR PROBLEM
PCOS / PCOD
NONE OF THEM
Other:
Required
14.
Any Other Disease specify
1 point
Your answer
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