New FormQuestiontare for healthcare"*" indicates required fieldsLinkedInThis field is for validation purposes and should be left unchanged. Nay.AI Early Adopters Program Registration FormName* Salutation Mr.Mrs.Miss.Ms.Dr. (Medical)Dr. (PhD)Other First Name Middle Name Last Name Date of Birth* DD dash MM dash YYYY Weight (kg)*Height (cm)*Member's Mobile Number**Living situation*alonewith husband/wife/partnerfamilyassisted facilityAdditional support*Trained healthcare assistantDomestic worker/helperAny other external live-in caregiverNoneAvailability*24 hrsDay time onlyNight time onlyVisiting domestic helper for cooking/household choresDriver/helper for outside activityLanguage spoken most*HindiBengaliTeluguMarathiTamilGujaratiKannadaOdiaMalayalamEnglishOtherNon-verbal (deaf/mute)AAC device userCan communicate in*EnglishHindiSign LanguageGenderMaleFemaleNon BinaryRecent hospitalizations (last 12 months)*YesNoDate MM slash DD slash YYYY ReasonCaregiver detailsCaregiver's Mobile Phone Number*Relationship with the member*HusbandWifeLive-in PartnerSonDaughterDaughter-in-lawSon-in-lawBrotherSisterNephew/NieceGrandchildFriend/Neighbour/OtherDo you want to add one more caregiver? Yes NoCaregiver's Mobile Phone Number*Relationship with the member*HusbandWifeLive-in PartnerSonDaughterDaughter-in-lawSon-in-lawBrotherSisterNephew/NieceGrandchildFriend/Neighbour/OtherThis form is filled bySelf (Member)Caregiver-1Caregiver-2OtherConsent to proceed* I consent to register me/the above person as a member and acknowledge that I have read and understood the terms and conditions fully.Define the non-binary gender status:Which of the following best describes the non-binary anatomy?*Has prostate and/or testesHas a uterus and/or ovariesHas breastsChildbirth:YesNoNumberPlease enter a number from 1 to 9.Last childbirth:Please enter a number from 1 to 99.Last Menstrual PeriodPlease enter a number from 1 to 99.Brest scan conducted:YesNoLast scan conductedPlease enter a number from 1 to 99.Please describe type of scan & result:Uterus scan conducted:YesNoLast scan conducted:Please enter a number from 1 to 99.Please describe type of scan & result:Any history of Urinary Infection (UTI):YesNoLast occurrence:Please enter a number from 1 to 99.Please describe onset frequency & related concerns:Prostate issues:No indication yetProbable enlargementFrequent PainsFrequent PainsDiagnosed past issue - curedProbable enlargementDifficulty starting urinationWeak or interrupted urine streamFrequent urinationRepeated urgency to urinateIncomplete emptying of bladderUnsure/unknown.Frequent Pains selectedDifficulty starting urinationWeak or interrupted urine streamFrequent urinationRepeated urgency to urinateIncomplete emptying of bladderUnsure/unknown.Primary diagnosis / main health concern*Current medicationsYesNoName Add RemoveDosage Add RemoveFrequency Add RemoveAny known allergies:*YesNoDetails Add Removeonset frequency Add Removelast occurrence Add RemoveFood habitStrictly VeganVegetarianIncludes EggNon-vegetarianWater intake per day5 liters or more3 to 5 liters1 to 3 litersless than 1 litreBowel movement*More than 3 times a day1-3 times a dayEvery 1-2 daysless than 3 times per weekirregular/variesUrinary LeakageNeverLess than once per monthA few times a monthDailyDuring SleepFrequentIrregular/variesMobility status*IndependentCane/walkerWheelchair mustBed-boundGaitStableUnstableWalking speedAverageFastSlowBalanceSteadyUnsteadyNeed SupportFalls in past 12 months*Never fell down1 to 3 times4 or more timesSaved multiple times by othersHave you ever noticed any unusual blood stain (Red/Brown/Near-black) in your (member’s) underclothes/clothesYesNoListdetailsonset frequencylast occurrence Add RemoveAssistance needed for*BathingDressingFeedingType of Urinary Leakage*Continuous/perpetual leakageLarge amount/soaks clothingA splashFew dropsStool appearanceSeparated hard small lumpsBig lumps with cracked uneven surfaceSmooth lumpsFluffy, Un-formed liquid or semi-liquidStool odour*Strong filthy odourUsual smellVery less or no smellStool colourBrown or Greenish YellowPale Yellow to WhiteMixed PatchesBlood in stoolNeverRed colour blood streaks up to 4 times a yearFrequent Red colour blood with stoolBlack Stool less than 5 times a yearRegular Black StoolCause of bowel issuesLong-time constipationRecent constipationIndigestionInadequate food intakeIrregular Bowel SyndromeDiagnosisClinically diagnosed in past 1 yearClinically diagnosed earlier but no change in symptom since thenUnder clinical investigationSelf-diagnosed with no professional consultation.AddressAddress* Street Address City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Is there any home safety concerns?:StairsBathroom wet floorsNo rails in bathroomInternet connection at the addressStable High-speed WiFiStable GSM 5GStable GSM 4GUntitledΔ
