RAF - Dr R K Jain
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Risk Assessment Form
The Form is designed by leading Cardiologists for preliminary assessment of your Cardiovascular Risk with respect to your personal data, work related stress, medical conditions etc. You understand that we assess your Risk based on information provided by you. Please submit accurate information.
All fields apart from Gender and Age are optional.
Please mention your email to get your Risk Assessment Report.
Personal Details
Gender *
Male
Female
Others
Age*
Height
Weight
Waist Circumference
Occupation
Business
Salaried
Student
Retired
Others
Industry
Job function
Medical Evaluation
Do you exercise regularly?
Yes
No
Are you a smoker?
Yes
No
If yes, how many cigarettes do you smoke per day?
0-2
3-5
5-10
>10
Do you consume alcohol?
Yes
No
If yes, how much is your alcohol intake per week ?
<120 ml
120-300 ml
>300 ml
How much time do you spend on mobile & laptop in a day?
0-3 hours
3-6 hours
>6 hours
Do you have any chest pain?
Yes
No
Do you have any breathlessness even with little or no physical activity?
Yes
No
Do you snore while sleeping ?
Yes
No
Do you wake up at night gasping for breath?
Yes
No
Do you have any edema or inflammation of legs?
Yes
No
Do you experience leg pain while walking <1 km?
Yes
No
Do you often experience lethargy and tiredness?
Yes
No
Do you have erectile dysfunction?
Yes
No
Do you have disturbed sleep?
Yes
No
How many hours do you sleep per day?
<4 hours
4-6 hours
>6 hours
Do you work in day-night shifts ?
Yes
No
Do you have any anxiety or work/relationship stress?
Yes
No
Do you have any history of illness >10 days at a stretch?
Yes
No
Do you have any history of surgery?
Yes
No
Please mention any other medical issues or past medical history
Family History
Medical Reports
Mention Lab Test Reports, if available.
Contact Details
Your information is safe with us. We utilise your data for the sole purpose of risk evaluation.
We do not engage in spamming, phishing or sharing data with third parties.
Name
Email*
Mobile No
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