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Comprehensive Health Assessment
Demographic Details
Full Name
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Comprehensive Health Assessment
Do you have immediate family history of any of the adjacent diseases?
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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?
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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?
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No
Do you always feel thirsty?
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Please Enter Do you always feel thirsty?
Yes
No
How many times do you wake up at night for Urination?
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Please Enter How many times do you wake up at night for Urination?
Any numbness or tingling sensation in your hand/feet?
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Please Enter Any numbness or tingling sensation in your hand/feet?
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No
Do you feel dizzy sometimes?
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Please Enter Do you feel dizzy sometimes?
Yes
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Are you on any Diabetes Medication?
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Please Enter Are you on any Diabetes Medication?
Yes
No
Are you on any long term medication?
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Please Enter Are you on any long term medication?
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No
Any symptoms that you are currently experiencing?
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Please Enter Any symptoms that you are currently experiencing?
Blurring of vision
Loss of consciousness
Headache
Eye pain
Chest pain
Others
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Do you have irregular period cycles?
Please Enter Do you have irregular period cycles?
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Are you gaining/losing weight rapidly?
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Please Enter Are you gaining/losing weight rapidly?
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Do you experience a lot of mood swings in a day?
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Please Enter Do you experience a lot of mood swings in a day?
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No
Do you have constipation?
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Please Enter Do you have constipation?
Yes
No
Do you have Hairfall?
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Please Enter Do you have Hairfall?
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Do you have Dry Skin?
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Please Enter Do you have Dry Skin?
Yes
No
Are you sensitive to heat/cold temperature?
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Please Enter Are you sensitive to heat/cold temperature?
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Are you experiencing any voice changes like hoarseness?
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Please Enter Are you experiencing any voice changes like hoarseness?
Yes
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Is there any swelling in front of the neck?
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Please Enter Is there any swelling in front of the neck?
No
Swelling present on noticing closely
Very large and obvious swelling
Do you have excessive facial hair growth?
Please Enter Do you have excessive facial hair growth?
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Do you have frequent acne?
Please Enter Do you have frequent acne?
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Have you experienced nipple discharge when neither pregnant nor breast feeding?
Please Enter Have you experienced nipple discharge when neither pregnant nor breast feeding?
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How many minutes in a week do you exercise?
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Please Enter How many minutes in a week do you exercise?
What does your diet predominantly contain?
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Please Enter What does your diet predominantly contain?
Fruits and Vegetables
Processed food
Junk food
Cereals
Pulses
Alcohol
Please Enter Alcohol
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Monthly or less
2-4 times in a month
2-3 times a week
4 times or more
Do you consume Tobacco in any form(Smoking/Chewing)?
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Please Enter Do you consume Tobacco in any form(Smoking/Chewing)?
Never
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BloodSugar Category
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Blood Pressure
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