Name

Father's Name

Spouse Name

Age

Sex

Address:- House No.

Floor

Sector/Block/Colony

City

Land Line

Mobile

Whatsapp Number

Your choice Allopathy Ayush

Homeopathy Siddha Unani Yoga Therapy Naturopathy Neurotherapy Accupressure Tibetan Doctors/Medical Experts Medical Astrology None of Them

PLEASE TELL YOUR PREFRENCE

General Medicine General Surgery Gynecology & Obstetrics Opthalmology (Eyes) ENT (Ear Nose Throat) Dermatology Child Specialist Cardiology (Heart) Endocrinology (Sugar, Thyroid, Hormonal Disorders)

Nephrology (Kidneys) Urology (Kidneys, Prostrate, Genito Urinary Tract) Gestroentrology (Stomach, Bowels) Hip & Join Replacement Vascular Surgery Neurology (Brain / Head) Orthopedics Kidney Transplant Physiotherapist

Breast Cancer Dental Chest Cancer IVF Dietician Psychiatry None of Them

LIFE STYLE INFORMATION

▸ Family History

Diabetes Stroke/ Brain Attack

Heart Attack/ Bypass Surgery/ Angioplasty Hyper Tension Dementia/ Memory Loss None of Them

▸ Smoking

> 2 Years 1 Pack a day

> 5 Years 1-5 Pack a day

> 10 Years 5 Pack a day

> 20 Years 10 Pack a day None of Them

▸ Alcohol

> 2 Years 1 Peg a day Daily

> 5 Years 2-3 Peg a day Once a week

> 10 Years 5 Peg a day Twice a week

> 20 Years 10 Pack a day More than 5 None of Them

TESTS

Blood Test Urine Bone Density Hearing

ECG Mammography X-Ray Spirometry

Will Be Coming Fasting for Blood Test None of Them

FOR FREE PRE-CAMP FREE BLOOD TEST, DO NOT

(i) Do not take in alcohol prevision night. (ii) No food after 10pm previous night

PREVIOUS HISTORY

Hypertension (Blood Pressure) Dyslipidemia (High Cholesterol) Diabetes (Sugar) Arthritis Joint Replacement Paralytic Stroke Drug Allergy None of Them

Want To Do

Blood Donation Organ Donation Eyes Donation None of Them

For any kind of help regarding filling this form please the contact at 0172-2920920, or email us at joshifoundations@gmail.com

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