Hypertension Screening

• Demographic Details
  Full Name *

  Enter First name

  Mr. Ms./Mrs. Master Baby

  Age *

  Please Select Date of Birth

  Age must be greater than 0 and less than 125 Years

  Months must be less than 12

  Days must be less than 31

  -

  -

  Days

  Mnth

  Yrs

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• Hypertension Screening
  name :  

  phone :  

  address :  

  id :  

  Do you have immediate family history of any of the adjacent diseases?  

  Please Enter Do you have immediate family history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Others None

  Do you have history of any of the adjacent diseases?

  Please Enter Do you have history of any of the adjacent diseases?

  Diabetes Hypertension Heart disease/Stroke Lipid disorders (Cholesterol) Thyroid disorders PCOD/PCOS Nutritional deficiencies (Vitamin B12/D/Calcium/Iron) Others None

  Are you currently pregnant?

  Please Enter Are you currently pregnant?

  Yes No

  Symptoms that you are currently experiencing are?

  Please Enter Symptoms that you are currently experiencing are?

  Blurring of vision Loss of consciousness Headache Eye pain Chest pain Others None

  Systolic

  / Systolic BP must be greater than Diastolic BP or Value must be in 40 to 160.

  Pulse

  Please Enter Pulse

  Cancel Back

  Submit