Edit

Mission Name -- Select -- ???? ?????

Mission Location -- Select -- High School STC

City -- Select -- Badayea Buridah Rass Unizah

Target Group -- Select -- Employee Other Student Visitor Worker

Mission Date

Applicant Name

Gender -- Select -- Male Female

Age

Age Group -- Select -- 0-15 15-25

Nationality -- Select -- Indian Saudi

Contact Number

Entered By

Smoking -- Select -- No Yes, current smoker Yes, ex smoker

Diabetes (DM) -- Select -- No Yes, on medication Yes, no medication

Hypertension -- Select -- No Yes, on medication Yes, no medication

Coronary Artery Disease (CAD) -- Select -- No Yes, on medication Yes, no medication

Dyslipidemia -- Select -- No Yes, on medication Yes, no medication

Other Disease

Physical Activity -- Select -- 1-2 Times/week 3-5 Times/week Daily Less than once/Week No

Oily Food -- Select -- Frequently (4-6 /Week) Never or rarely Occasionaliy (2-3/Week)

Fruits & Vegetables -- Select -- 1-2 serving 3-4 serving 5 or more serving Less than 1 serving

Sugar -- Select -- Daily (7 or more times/Week) Frequently (4-6 /Week) Never or rarely Occasionally (2-3 /Week)

Family History - DM -- Select -- Yes No

Family History - HTN -- Select -- Yes No

Height

Weight

Systolic Blood Pressure (SBP)

Diastolic Blood Pressure (DBP)

Random Blood Sugar (RBS)

Score

Doctor -- Select -- Dr. Badi Dr. Shaik

Recommendation

Time of Survey

Urgent Contact -- Select -- Yes No