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Buy Insurance Step 5
demo.deadhappy
2023-01-17T12:27:56+00:00
We are just getting done, hang on!
Have you been diagnosed before or are currently suffering from any of the following diseases?
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First Name
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Last Name
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Date
DD slash MM slash YYYY
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Age
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Gender
Male
Female
Gender X
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Mobile Number
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Email
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Current Height (cm)
(Required)
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Current Weight (kg)
(Required)
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Occupation
(Required)
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Monthly Income (PKR)
(Required)
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Do you intake Tobacco or Nicotine in any form? Yes or no
Yes
No
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Do you intake Tobacco or Nicotine in any form? Yes or no
0-5 times
5 to 10 times
10 to 20 times
Can't specify
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Consume Alcohol Yes or no
Yes
No
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Consume Alcohol Yes or no
Social Drinking
Regular Drinking
Select
Cancer
Hepatitis B
Hepatitis C
Diabetes
Coronary Artery Disease
Heart Attack
Heart Failure
Ischemic Heart Disease
Heart Valvular Disease
Cardiac Arrhythmia
Kidney Disease
High Blood Pressure
Thyroid Disorder
Liver Cirrhosis/Liver Failure
Stroke
Paralysis
Musculoskeletal Disorders
Chronic Obstructive Pulmonary Disease
Nervous Disorders (Depression, Psychiatric Disorder)
Bleeding Disorder
Anaemia
Deformity or Disability
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I don’t want to contribute
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