Create Survey | Samarppanam

1. Do you have high blood pressure?*

Yes No

1.1. Which of the following is your blood pressure ?*

140/90 mmHg or More 120/80 mmHg or Lower 120-140 mmHg / 80-90 mmHg

2. Do you have diabetes ?*

Yes No

2.1. Which of the following is your blood sugar level?*

More than 150 mg/dl less 126 mg/dl 126-150 mg/dl

3. Do you have high cholesterol?*

Yes No

3.1. Which of the following is your cholesterol level ?*

more 250 mg /dl less 200 mg/dl 200-250 mg/dl

4. Do you smoke?*

Yes No

5. Do you consume Alcohol?*

Yes No

6. Do you use any narcotic substances*

Yes No

7. Do you chew tobacco?*

Yes No

8. Have you ever had a stroke?*

Yes No

8.1. Have you consulted a neurologist or physician and been treated ?*

No Yes

9. Has anyone in your family had a heart attack / Stroke?*

Yes No

9.1. Have you consulted a neurologist or cardiologist and been treated ?*

No Yes

10. Do you experience palpitations?*

yes no

10.1. Have you consulted a physician or cardiologist and been treated?*

No Yes

11. Have you ever experienced sudden weakness in your limbs, difficulty in speaking, unsteadiness or weakness of your face?*

Yes No

11.1. Have you consulted a neurologist or physician and been treated ?*

No Yes

12. Have you had paralysis, stroke, or heart attack in the last year?*

Yes No

12.1. Have you consulted a neurologist or cardiologist and been treated ?*

No Yes

13. Do you eat fast food / Fried foods on a regular basis?*

Yes No

14. Do you consume vegetables more than 5 times a week?*

No Yes

15. Do you eat more than 5 servings of fruit in a week?*

Yes No

16. Do you exercise regularly?*

Yes No

17. Do you get chest pain while walking, climbing stairs, or when you are anxious ?*

Yes No

17.1. Have you consulted a cardiologist or physician and been treated ?*

No Yes

18. Do you have breathing difficulty ?*

Yes No

18.1. Have you consulted a physician or cardiologist and been treated ?*

No Yes

19. Do you experience heartburn?*

Yes No

19.1. Have you consulted a gastroenterologist or cardiologist and been treated ?*

No Yes

20. Do you experience any sudden loss of consciousness or fainting?*

Yes No

20.1. Have you consulted a neurologist or cardiologist and been treated?*

No Yes

21. Do you experience memory loss ?*

Yes No

21.1. Have you consulted a neurologist and been treated ?*

no Yes

22. Do you experience unexplained sadness ?*

Yes No

22.1. Have you consulted a psychiatrist and been treated?*

No Yes

23. Has your body weight increased recently?*

Yes No

23.1. Have you consulted a physician or endocrinologist and been treated ?*

No Yes

24. Do you frequently experience headache ?*

Yes No

24.1. Have you consulted a neurologist or physician and been treated ?*

no Yes

25. Do you experience tremor or difficulty in walking ?*

Yes No

25.1. Have you consulted a neurologist or orthopedician and been treated ?*

No Yes

26. Have you lost more than 5 kilograms in the past 6 months?*

Yes No

26.1. Have you consulted a physician or endocrinologist and been treated?*

No Yes

27. Do you experience loss of appetite?*

Yes No

27.1. Have you consulted a gastroenterologist and been treated ?*

No Yes

28. Do you experience difficulty in swallowing?*

Yes No

28.1. Have you consulted a gastroenterologist and been treated?*

No Yes

29. Do you frequently experience abdominal pain?*

Yes No

29.1. Have you consulted a gastroenterologist and been treated?*

No Yes

30. Do you notice blood in your stool*

Yes No

30.1. Have you consulted a gastroenterologist and been treated?*

No Yes

31. Do you have lumps or swelling in your neck or breast?*

Yes No

31.1. Have you consulted a surgeon and been treated?*

No Yes

32. Do you have non-healing wounds or sores?*

Yes No

32.1. Have you consulted a surgeon or skin specialist and been treated ?*

no Yes

33. Do you have skin discoloration, such as black patches or bleeding from the skin?*

Yes No

33.1. Have you consulted a skin specialist and been treated ?*

No Yes

34. Do you experience excessive menstrual bleeding?*

Yes No

34.1. Have you consulted a gynecologist and been treated ?*

No Yes

35. Does anyone in your family have a history of cancer?*

Yes No

35.1. Have you consulted a physician or oncologist (cancer specialist) and been screened?*

No Yes

36. Do you have persistent cough ?*

Yes No

36.1. Have you consulted a physician or chest physician (pulmonologist) and been treated ?*

No Yes

37. Do you have sputum that is mixed with blood ?*

Yes No

37.1. Have you consulted a physician or pulmonologist and been treated?*

No Yes

38. Do you see Blood in your urine?*

Yes No

38.1. Have you consulted a physician or urologist and been treated?*

No Yes

39. Do you have froth in your urine ?*

Yes No

39.1. Have you consulted a physician or nephrologist and been treated ?*

No Yes

40. Do you have epilepsy or fits ?*

Yes No

40.1. Have you consulted a neurologist or physician and been treated ?*

No Yes

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