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a.

*Fc /Living {d/Dead


10. "sffterft-fi ift{iT /Family History 3ilq/As( -rs{ fPIil /State of Healtt qq'*- $ffi 3ilq/Ase at death TdI 6,T fiI{ullOause of death
frar / Fattrer
grdl / Mother
/ Brothers
s{r$
frftr I 1iving.............
Tfr / Dead....
E6t/sisters
frffa/uving...........
I rVDead.................
qft/gftlwifetHusband
qd/chitdren
frfra/uving..,.......
Ht/Dead..........
ffifi Effi/Personal History Tfl rt qr r& +flGq -
.rRstri Ei't + q{r ft-{tsr RGq
Answers'Yes'or'No' lf 'Yes', Please give full details

6') Rn qTq+ ffi dq E+ + trt{ ffi qS ffi + ft+ frs+


qfr. lqr6 + slB-fi rrq n-.6- sq-qp ff 3{HTq-fi-dr {fr d,
ffifrft-"r+ t q{FEt frm tl
a) During lhe hst fwe years dkJ i,ou consult a Medical Practitioner fol
any aiknent requiring treatrnent lor more than a week?

RG'dHr + ftq GtS srsdti{ qr rfrfq dq + qrfud frqr rrqr ta


b) Have you ever been admitted to any hospltal or nursing home for
general check up, observation, treatment or operation?
T) flr 3{rq m fq s# + dTT sreq *' 3{TeIR qr STs+

6r{'t wgqRrdrttz
c) Have you remained absent from place of work on grounds
of health during the last 5 years?
q) eri 3fiq q5'ar, t-a, 6qq, frE."s, Td, cRq. qrergcu-saT
d-dft'd fr{ft 1H + q'fr fitr{ t qr gs srq'SBil tz
d) Are you suffering from or have you ever suffered lrom ailments pertaining
to Liver, Somach, Hearl LunSE, Kilney. Brain or Nervous systernl
s) iFIt 3IIq r{gT6, elir, 3Et { FnErtr r{{I{,
{q, A-{{, Itr{q, -fra
'ffi,r;&,*;ffi **ffi,*t q w g# t,
e) Are you suffering from or have you ever suffered lrom Diabetes,
Tuberculosis, High Blood Pressure, Low Blood Pressure, Cancer,
Epilepsy, Hernia, Hydrocele, Leprosy or any other disease?
i{) Hr s{rqfi'?r{Iffi q-r*a {'srs Erc q] <Tt[ f?
f) Did vou ever have anv bodilv defect or deforniitv?
t9) Err 3iTrr 4.'fr S{--{rIk. gq t qr e{rqfrt Efu erft ti
o) Did vou ever have anv accident or iniurv?
q) Hr snq tfE{ { t fa;$ isr 3q-qFT 4-{t A s{?rqr Giqr tz
h) Do you use orhaveyou ever used :

i) qaqH ,/Alcoholic drinks


ii) rltrt qPf/Narcotir:s
iii) sa-q etS cr({. (atlAnv other druos
fr-S cfi Gq t iFiltp'/Tobacco in any form
iv)
F) rfi{tr : e*q*- {areq q1 ftrfr A'S tr
i) What has been vour usual state of health?
F) er sTrq-frf qlfi q-+a s+* qr qs,s fr q-cE t FrB,so't
qnqf, 3q-qR ql fq qftqT q-{+ ff effilq-fi-dr.rS t, qr
TtcT{ + silq F{ ffi t ftq eu-un t tt tz
l) Have you ever required or at present availing / undergoing medica
advice, treatment or tests in connection with Hepatitis B or AlDs
related condition.
12 fr{r frfr-dsr qrq-+ + s.qqI. s& tr +#{E{ * g+ aw 6q (-r$q') E-sr+ (frr {)
ft.q'.t Frd q+l ffi Height (in cms) Weight (in Kgs)
ln non-medical cases, please state exact Height in Cms,
and Weight in Kgs. (without shoes)
-3-
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