AYF Health Survey

This is a survey done to note the problems faced by the people in Healthcare by Aadiya Youth Foundation to make a note of the beneficiaries that are applicable to receive the benefits provided by the NGO.

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Welcome, Mr. Surveyor , enter details to complete the health survey. (*) Marked fields are mandatory to be filled.

Basic Information

Full Name *

Date of Birth *

Aadhar No *

Attach Aadhar File * (.jpg / .png file in less than 1 MB size)

Voter Card No *

Attach Vote Card File (.jpg / .png file in less than 1 MB size)

Gender *

Caste *

Schemes utilized provided by Govt. (Select Multiple)

Address Information

Area *

Flat Name & No. *

Street *

Nearest Landmark *

City *

PIN Code *

Ward No *

Contact No *

Alternate Contact No

Email ID

Family Information

Family Type

Total number of members in the family (including grandparents, parents and children) *

Grandparents *

Parents *

Children *

Others *

Include information of those 18 or above and 60 or below only

Member 1 Voter Id Number

Member 1 Aadhaar Card Number

Member 2 Voter Id Number

Member 2 Aadhaar Card Number

Member 3 Voter Id Number

Member 3 Aadhaar Card Number

Member 4 Voter Id Number

Member 4 Aadhaar Card Number

Member 5 Voter Id Number

Member 5 Aadhaar Card Number

Member 6 Voter Id Number

Member 6 Aadhaar Card Number

Health And Employment

Blood Group Type *

Last Blood Donated Month *

Major Health Problems *

How many times do you visit a doctor? *

Any Health Insurance *

If yes, Specify

Status of Employment *

Do you have PF/Pension Account? *

Do you have Income Tax File? *

Annual Income *

If there is a Health card where you can get Discount on Diagnostic Centers, Yoga Centers, Gyms and Physiotherapy Centers, will You Buy for yourself and family? *