Full Name Mobile
Email Address
Suburb Pincode
Date Of Birth (dd/mm/yyyy) Residence Phone No.
Organization Designation
Height in ft/inches Weight in Kgs

Core Medical

Pulse rate

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Blood Pressure - Systolic

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Blood Pressure - Diastolic

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In case of Diabetes, since when ?

1 year
2 years
3 years
4 years
5 or more years
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BSL

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Fasting

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PP [post prandials]

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Insulin

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Tablet

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Haemoglobin Hb

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Cholesterol

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TriglyceridesS

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Creatinine

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Uric Acid

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T1

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TSH

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Follow Up Date (dd/mm/yyyy) Grand Total