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Home Medical Services Al Safwa Healthcare Program Register Today

Name*

Family Name*

Gender*

Date of Birth*

Mobile*

Email*

Preferred Date of Appointment*

Have you previously had a medical checkup done?

Less than 1 yr More than 1 yr Never

Which of the following do you suffer from?

Diabetes

Yes No Dont Know

Hypertension

Yes No Dont Know

High Cholestrol

Yes No Dont Know

Heart Disease

Yes No Dont Know

Bronchial Asthma

Yes No Dont Know

Overweight / Obesity

Yes No Dont Know

Special Habits (Please tick as appropriate)

Do you smoke?

Yes No

Do you drink Alcohol?

Yes No

Royale Hayat Hospital
P.O. Box 179, Hawalli
32002, Hawalli Kuwait.

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