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ANC CHEK UP () ()
WALSH HOSPITAL () ()
SELF () ()
DR. SAYANTAN GHATAK () (MBBS)
DR. SUTAPA CHATTOPADHYAY (57141) (MBBS, DCH)
UPHC1(COLLECTED BY SUBHAJIT DUTTA) () ()
Date
Address
Contact No
Ward No
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Contact Person
Chargable
*
No
Yes
Weight
KG
RSBY/Swasthya Sathi Card Holder
--Select--
YES
NO
Occupation
Smoking
NO
YES
Chewing / Snuffing
NO
YES
Alcohol Consumption
NO
YES
Less Physical Activity
NO
YES
Diabetes
NO
YES
CVD
NO
YES
Stroke
NO
YES
Blood Sugar
Oral Cavity
Normal
Abnormal
Breast Exam
Normal
Abnormal
Visual Inspection
Normal
Abnormal
Other