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
sachin
District
*
Pin Code
*
Address
*
Company Name
Select Company
THINK Gas Bhopal Private Limited
THINK Gas Begusarai Private Limited
THINK Gas Ludhiana Private Limited
THINK Gas Distribution Private Limited
Bagpat Green Energy Private Limited
THINK LNG Investments Private Limited
Other
Critimedconsult
Cube Highways
WMP
KHEPL
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
Submit Report
