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Registration Form for Free Diabetes Awareness Camp from 6th April – 9th April, 2017

Please keep your basic details like weight, height, blood pressure, and scanned report of test ready while registering online.

Name


Gender


Age


Qualification


Profession/Job

Address


Mobile Number


Whatsapp Number


Your Email Address


Are you suffering from Diabetes ?


Duration of Diabetes(In Years)


Are you taking treatment for Diabetes ?


How many years are you on treatment for diabetes?


Are you taking medicine/tablets for Diabetes?


Are you taking insulin ?


Any Alternative medicine are you following?AyurvedaHomeopathyUnaniOthersNone
Do you have Eyes Problem?


Do you have Heart Problem?


Do you have Pain/Numbness in legs?


Do you have Kidney Problem?


Write about your other medical problems if you have?


Whether your father has/had the following problem(s)?DiabetesHigh Blood PressureHeart AttackStrokeNone
Whether your mother has/had the following problem(s)?DiabetesHigh Blood PressureHeart AttackStrokeNone
Whether your brother(s) has/have the following problem(s)? DiabetesHigh Blood PressureHeart AttackStrokeNone
Whether your sister(s) has/have the following problem(s)?DiabetesHigh Blood PressureHeart AttackStrokeNone
Height (in cms)


Weight (in kg)


Waist Circumference (in cms)


Blood Pressure(systolic/diastolic)


Please upload scanned report of your blood/lipid profile if you have. (Acceptable formats are jpg, jpeg, png, pdf, gif only)