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Personal Details
Name:
Date of Birth:
Father Name:
Mother Name:
Address:
Pin Code:
City:
Mobile Number:
Email Id:
Aadhaar Number:
PAN Card Number:
Nomination Name:
Nomination D.O.B:
Height:
Weight:
Vaccination Date:
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Education & Income
Education:
Company Name:
Annual Income:
Bank Name:
Account Number:
IFSC Code:
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Family History
Family Members & Age (Living):
Select Relation
Father
Mother
Brother
Sister
Wife
Child
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Dead Members & Age (if any):
Select Relation
Father
Mother
Brother
Sister
Wife
Child
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Medical History
Alcoholic Drinks:
Yes
No
Narcotics:
Yes
No
Any other drugs:
Yes
No
Tobacco in any form:
Yes
No
Whether any of the following health related issues mentioned in a,b,c is/are faced by you ? *
a) During last 5 years did you consult a Medical Practitioner for any ailment requiring treatment for more than a week?
Yes
No
b) Have your ever been admitted to the hospital or nursing home for general check up, observation, treatment or operation?
Yes
No
c) Have you remained absent from the place of work on grounds of health during the last 5 years?
Yes
No
I am fully fit and I am not taking any medicine of BP / Sugar.
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Documents
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