FemaleMaleOther

Date of Birth

Preferred Communication Language
EnglishHindiMarathiGujarati
Other

1.Do you have any of below conditions?
Heart ConditionLung ConditionNone
Other Conditions(if-any)

2.Do you have any of below ?
DiabetesBlood PressureThyroidIncreased WeightArthritis
Other Conditions(if-any)

3.Do you have any of the following habits?
SmokingTobaccoAlcoholNone
Others(if-any)

4.Do you have any of the following symptoms
BreathlessnessCoughTirednessChest PainSwelling of feetJoint PainMuscle PainNone
Others(if-any)

5.Any prior surgeries?
NoYes
Specify(if-yes)

6.Any prior Hospitalization?
NoYes
Specify(if-yes)

7.Are you on Oxygen?
NoYes

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