Health Survey
Name
*
E-mail
Mobile
*
Gender
*
Male
Female
Age
*
State
*
Select State
Andaman & Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadra & Nagar Haveli
Daman & Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu & Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Odisha
Puducherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
Uttarakhand
West Bengal
District
*
Pin Code
*
Address
*
Company Name
Select Company
Other
EMP-Code
*
Relationship
*
Select Relation
Self
Wife
Son
Daughter
Mother
Father
Annual Income
*
Less than 2.5 lakh
More than 2.5 lakh
Family Health Survey
Would you be interested in supporting your maid/servant( and her family of 4) by purchasing a Complete Health Cover for a year at Rs 4,200 plus GST?
*
Includes:
Free OPD Consultation
Free Medication
Free Lab Tests
Hospital Care up to Rs 1.5 lakhs
Hospitalisation valid after 3 months of purchase
If you are interested in the entire family, Please click on Yes otherwise No.
Yes
No
Diseases
*
NCD
Diabetes
Hypertension
CAD
Stroke
Asthma
Dyslipidemia
Hypothyroidism
Hyperthyroidism
Cancer
Communicable Diseases (history of the following symptoms in last 3 months)
Acute Febrile Illness
Acute Gastrienteritis
URTI
LRTI
Dengue ( last one year )
Hepatitis
Typhoid
Measles
HIV
TB
Superficial or systemic fungal infections
Genital ulcer/ discharge syndromes
Maternal and Child
Preterm birth
Low Birth weight
Ante Partum Haemorrage
Maternal Death
Maternal Anemia
LSCS
GDM
Still birth
Under 5 Death
Childhood pneumonia
Acute Diarrhoea in under 5 children
Under 5 child anemia
Completion of primary immunization
Dysfunctional Uterine Bleeding
Nutritional
Anemia
Documented ( lab tested ) vit D deficiency
Documented ( lab tested ) B12 deficiency
Documented calcium deficiency
Osteoporosis
Geriatric
Parkinsonism
Documented memory disorder
Essential tremors
Cataract
Benign prostatic hypertrophy
No Disease
Helped by
Submit Report
