Comprehensive Health Assessment

• Demographic Details
  Full Name

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  • Ms./Mrs.
  • Master
  • Baby

  Mr. Ms./Mrs. Master Baby

  Gender *

  Please Select Gender

  M

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  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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• 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

  Are you experiencing any voice changes like hoarseness? *

  Please Enter Are you experiencing any voice changes like hoarseness?

  Yes No

  Is there any swelling in front of the neck? *

  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?

  Yes No

  Do you have frequent acne?

  Please Enter Do you have frequent acne?

  Yes No

  Have you experienced nipple discharge when neither pregnant nor breast feeding?

  Please Enter Have you experienced nipple discharge when neither pregnant nor breast feeding?

  Yes No

  How many minutes in a week do you exercise? *

  Please Enter How many minutes in a week do you exercise?

  What does your diet predominantly contain? *

  Please Enter What does your diet predominantly contain?

  Fruits and vegetables Processed food Junk food Cereals Pulses

  Alcohol

  Please Enter Alcohol

  Never 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)? *

  Please Enter Do you consume Tobacco in any form(Smoking/Chewing)?

  Never Reformed Current

  Weight *

  Please Enter Weight

  Height  

  Cms

  Feet

  Inches

  Waist *

  Please Enter Waist

  Hip *

  Please Enter Hip

  Blood Sugar

  Please Enter Blood Sugar

  Pulse

  Please Enter Pulse

  BMI

  Please Enter BMI

  WHR

  Please Enter WHR

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