Intake form

Name *

Email address *

What is your age group?

Do you have any existing health conditions?

Please select at least one option.

Diabetes

Hypertension

Heart Disease

Obesity

Asthma

None

What health metrics would you like to monitor?

Please select at least one option.

Heart Rate

BMI

Body Fat

Blood Pressure

Blood Sugar

Pulse Oximetry

How many family members will be using the service?

What type of medical equipment do you currently use?

Please select at least one option.

Smart Weight Scale

Blood Pressure Monitor

Pulse Oximeter

Blood Sugar Monitor

None

Which platform do you prefer for monitoring your health?

What is your preferred method for health screening appointments?

Do you have a primary care physician?

How did you hear about vikshara health services?

Additional questions or comments

Vikshara Health Services