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Cure-Online@nirvana.com

form to be filled by the patient Online

The purpose of this form is to collect information from you about your calamities regarding health .

This information is completely secret & never be disclosed.

This  form  is  divided  into  the  following  sections  :
Fill out the information in each section as requested. Then submit the form. You will receive a message from us shortly.
s-format="TEXT/TSV" s-label-fields="TRUE" s-builtin-fields="Date Time REMOTE_NAME REMOTE_USER HTTP_USER_AGENT" s-form-fields -->

SECTION A -- @ddress

  1. Your Name

  2. Age


    3. None 1-5 hours 5-10 hours 10-20 hours More than 20 hours
     
  3. We would like to send you some literature. What is your mailing address?
  Name    
  Street    
  City                                          Country    
  State                                        ZipCode    
  Religion          Age                Occupation  
  Marital Status                                 Phone  
   E-mail:      
  Website     
  Food Habit             Vegitarian         Non-Vegitarian
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SECTION B -- Disease history

HELP

Details of Previous diseases & drugs used

Chief complaint

Detailed history of present illness

the cause

onset & course with date should be given

Personal History

Family history


These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. How would you rate this survey?

    2.  

     
     
     
     
     

    Bad Poor Fair Good Excellent
     

  2. What is your favorite color?

    3.  

     
     
     
     
     


     

  3. Select the subject areas you are most interested in:

    4.  

     
     
     
     
     

    History
    Geography
    Mathematics
    Economics
    Literature
     

  4. Here's another way of collecting address info without using fixed-width text:

    5.  

     
     
     
     
     

    Username
    Password

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SECTION C -- Title of this section

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.
  1. Which of our products do you currently own?
    2. SKU-01     SKU-04     SKU-07     SKU-10
SKU-02     SKU-05     SKU-08     SKU-11
SKU-03     SKU-06     SKU-09     SKU-12
  2. Please enter any additional comments regarding our products or services:

    3.  

     
     
     
     
     


     

  3. Select a month from the following list, which shows 6 elements at a time:

    4.  

     
     
     
     
     

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FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

This explains how we plan to use the information you provide to us. We will also explain what benefits you receive from helping us in this way.

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Author information goes here.
Copyright © 1995 [OrganizationName]. All rights reserved.
Revised: April 07, 2000.