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Personal Details
First Name	^*	Middle name
Last Name	^*
E-Mail	^*
Password	^*	Re-enter Password	^*
Date of Birth	^*	Sex
If You Forget Your Password...
Security Question	^*
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