JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Patient Profile (Mareez Ki Maloomaat)
Please use one form for only one family. Do not use more forms for the affected patients of the same family instead, put their information in one form.
Urdu: Aap se darkhwaast he k aik form sirf aik khandaan k liey istemaal karein. Aik hi khandaan k mutaasira mareezon k liey mazeed form istemaal na karen, balkay aik hi form pe un ki maaloomaat bhi likh dein.
Sign in to Google
to save your progress.
Learn more
Which disease is present in the person?
Urdu: Mareez konsi beeamari mein mubtla he?
Childhood Glaucoma (Bachon ka Kala Motia)
Childhood Cataract (Bachon ka Safaid Motia)
Retinitis Pigmentosa (Andhraata)
Deafness (Behra pan)
Mental Retardation (Dimaaghi kamzori)
Stuttering/Stammering (Haklaana)
Other:
Clear selection
What is the name of the patient?
Urdu: Mareez ka naam kia he?
Your answer
What is the name of patient's father?
Urdu: Mareez k waalid ka kia naam he?
Your answer
What is the age of the patient?
Urdu: Mareez ki umar kia he?
Your answer
What was the age of the patient at the time of diagnosis?
Urdu: Marz ki taskhees k waqt mareez ki umar kia thi?
Your answer
How many individuals of the family of the patient (other than this patient) suffer from the same disease?
Urdu: Mareez k khandaan mein kitnay log (is mareez k ilawa) is marz mein mubtala hein?
Your answer
What is the relation of these affected individuals of the family with the patient?
Urdu: Khandaan mein in mutaasir honay waalay afraad ka mareez k saath kia rishta he?
Your answer
Write atleast two or more phone numbers in the available space of the affected patients and/or their family heads.
Urdu: Di gai jaga pe mutaasira mareez aur/ya un k khandaan k sarbrah ke do ya do se zyaada phone number likhein.
Your answer
Write the address in the available space of the affected patient and/or their family heads.
Urdu: Di gai jaga pe mutaasira mareez aur/ya un k khandaan k sarbrah ka pata likhein.
Your answer
From which city and country does the patient belong?
Mareez ka taaluq kis shehar aur mulk se he?
Your answer
What is your name and how do you know the patient? Please write your contact number.
Apka kia naam he aur aap mareez ko kese jaantay hein? Apna contact number likhiay.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
