Comprehensive Health Assessment

• Demographic Details
  Full Name *

  Enter First name

  Mr. Ms./Mrs. Master Baby

  Gender *

  Please Select Gender

  M

  F

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

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  Days

  Mnth

  Yrs

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• Comprehensive Health Assessment
  Do you have immediate family history of any of the adjacent diseases? *  

  Please Enter Do you have immediate family history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Others None

  Do you have history of any of the adjacent diseases? *

  Please Enter Do you have history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease/Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Nutritional deficiencies (Vitamin B12/D/Calcium/Iron) Others None

  Do you have any complains of back pain in last 3 months? *

  Please Enter Do you have any complains of back pain in last 3 months?

  Yes No

  Are you currently pregnant?

  Please Enter Are you currently pregnant?

  Yes No

  Do you always feel thirsty? *

  Please Enter Do you always feel thirsty?

  Yes No

  How many times do you wake up at night for Urination? *

  Please Enter How many times do you wake up at night for Urination?

  Any numbness or tingling sensation in your hand/feet? *

  Please Enter Any numbness or tingling sensation in your hand/feet?

  Yes No

  Do you feel dizzy sometimes? *

  Please Enter Do you feel dizzy sometimes?

  Yes No

  Are you on any Diabetes Medication? *

  Please Enter Are you on any Diabetes Medication?

  Yes No

  Are you on any long term medication? *

  Please Enter Are you on any long term medication?

  Yes No

  Any symptoms that you are currently experiencing? *

  Please Enter Any symptoms that you are currently experiencing?

  Blurring of vision Loss of consciousness Headache Eye pain Chest pain Others None

  Do you have irregular period cycles?

  Please Enter Do you have irregular period cycles?

  Yes No

  Are you gaining/losing weight rapidly? *

  Please Enter Are you gaining/losing weight rapidly?

  Yes No

  Do you experience a lot of mood swings in a day? *

  Please Enter Do you experience a lot of mood swings in a day?

  Yes No

  Do you have constipation? *

  Please Enter Do you have constipation?

  Yes No

  Do you have Hairfall? *

  Please Enter Do you have Hairfall?

  Yes No

  Do you have Dry Skin? *

  Please Enter Do you have Dry Skin?

  Yes No

  Are you sensitive to heat/cold temperature? *

  Please Enter Are you sensitive to heat/cold temperature?

  Yes No