RegistrationRegistrationFull Name *Middle NameDate of Birth *Phone *Living Situation *Living SituationAloneWith FamilyAssisted FacilityLanguages SpokenLanguages SpokenEnglishMother TongueGenderMaleFemaleAny Existing Health IssuesYesNoRecent hospitalizations (last 12 months)YesNoDateReasonCaregiver DetailsPhone Number *Email Address *Relationship with memberConcent to proceed *I agree to initial registration and contactField GroupChild BirthChild BirthYesNoLast Child BirthLast Menstrual Period:Breast CancerYesNoYears AgoType of ScanFindingClearObservationUterus ScanYesNoYears AgoType of ScanFindingClearObservationUTIYesNoOnset Frequency & Last dateFindingClearObservationProstate issues:No indication yetProbable enlargementFrequent PainsDiagnosed issue under treatmentDiagnosed past issue - curedField GroupPrimary diagnosis / main health concernCurrent medicationsYesNoFood HabbitStrictly VeganVegetarianIncludes EggNon-vegetarianWater intake per dayMore than 5 liters3 to 5 liters1 to 3 litersless than 1 litreBowel movementMore than 3 times a day1-3 times a dayEvery 1-2 daysless than 3 times per weekirregular/varriesUrinary LeakageNeverLess than once per monthA few times a monthDailyDuring SleepFrequentIrregular/varriesGaitStableUnstableAverageFastSlowMobility statusIndependentCaneWalkerwheelchairbed-boundFalls in past 12 monthsField GroupADL assistance neededbathingdressingfeedingtoiletingtransferringcontinenceIADL assistance neededshoppingmeal prephousekeepingmed managementtransportationfinancesHome safety concernsstairsbathroom railspoor lightingclutterpetsField GroupType of Urinary LeakageContinuousperpetual lekageLarge amountsoaks clothingA few mlDropsCause of Urinary LeakageUTI (Infection): Onset per yearNeurological issuesCoughing/Sneezing/ExertionurgencyDribbling after urinationField GroupBowel appearenceSeparated hard small lumpsBig lumps with cracked uneven surfaceSmooth lumpsFluffyUn-formed liquid or semi-liquidBowel odourStrong filthy odourUsual smellVery less or no smellBowel colourBrownish or Greensish YellowFaint Yellow to WhitishMixed PatchesBlood in bowelNeverRed colour blood streaks less than 5 times a yearFrequent Red colour blood with stoolBlack Stool less than 5 times a yearRegular Black StoolCause of bowel issueslong-time constipationrecent constipationindigestioninadhequate food intakeIBSDiagnosisClinically diagnosed within 1 yearClinically diagnosed earlier but no chane in symptom after thatUnder investigationSelf-diagnosed with no professional consultationDo you have any question to ask or mention something important?Field GroupPrimary AddressHouse NumberFlat/ Floor NumberStreet DetailsArea DetailsCity/Town/VillageStatePINInternet connection at the addressStable WiFiStable GSM 5GStable GSM 4GWeak GSM signalsField GroupSecondary AddressType of address: Additional residence / relative's place where the member visits often / office that member visits oftenHouse NumberFlat/ Floor NumberStreet DetailsArea DetailsCity/Town/VillageStatePINInternet connection at the addressStable WiFiStable GSM 5GStable GSM 4GWeak GSM signalsSubmit
