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Personal Details

 First Name *  Middle name
 Last Name *
 E-Mail *    
 Password *  Re-enter Password *
 Date of Birth *  Sex

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 Your Answer *

Parent's Details

 Mother's Name  Mother's Ocupation
 Father's Name  Father's Occupation

Contact Info

 Address City
 State  Pin/Zip
 Country  
 Residence Phone  Office Phone
 Mobile    

Health Record

 Born at  Mode of Delivery
 Birth Weight   Grams.
 Any complication during pregnancy? 
 Any complication during delivery?
 Did baby cry immediately after birth?  
 Was the child admitted in hospital?
 Was there any injury?
 Any previous surgery?  

History

 Allergy
 Any other information

Family History of

 Diabetes  Hypertension
 Asthma  Tuberculosis
 Cardiac/Heart  Others

Feeding and Dietary History

 Breast feeding upto  months  
 Solid introduced at  months  
 
 
 
   
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