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Health survey
Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
Name of the participant
Select one or more answers
Asad hussain
Answer 2
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2
What do you say about your over all health
Select one or more answers
Having good physical health
Moderate physically impaired
Severely physically impaired
Totally physical impaired
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3
Do you have any chronic diseases
Select one or more answers
Yes
No
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4
Do you have any hereditary condition diseases
Select one or more answers
High blood pressure
Diabetes
Hemophilia
Thalassemia
Huntington
Other (please specify)
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5
Are you habitual to drugs and alcohol
Select one or more answers
Yes to both
Only to drugs
Only to alcohol
I am not habituated to either
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6
Over the past 2 weeks, how often have you felt nervous anxious,or on edge
Select one or more answers
Not all
Several days
More days than not
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7
Are there under age of 12 in your house hold
Select one or more answers
Yes
No
None of these
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8
How often do you get a health check up
Select one or more answers
Once in three month
Once in sic months
Once a year
Only when needed
Never get it done
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9
Gender
Select one or more answers
Male
Answer 2
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10
In which year you born
Select one or more answers
2005
Answer 2
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11
To which ethnic group do consider yourself belonging to
Select one or more answers
Kanpur
Answer 2
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12
Would you describe the area in which you live as being city,town,village or country side
Select one or more answers
City
Answer 2
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13
How many people are living in tour household, including you
Select one or more answers
5
Answer 2
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