Step 1: Demography

First Name
Your First Name
Field is required!
Date of Birth
Select a date
Field is required!
Address
Your Address
Field is required!
Religion
  • - select a option -
  • Christianity
  • Islam
  • Sikhism
  • Hinduism
- select a option -
Field is required!
Marital Status
  • - select a option -
  • Single
  • Married
  • Divorced
- select a option -
Field is required!
Number of Years spent in the company
-
+
Field is required!
Any promotion denial?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Are you satisfied with your pay?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Last Name
Your Last Name
Field is required!
Email address
Your Email Address
Field is required!
Phone number
Your Phonenumber
Field is required!
Tribe
Field is required!
Gender
  • - select a option -
  • Male
  • Female
  • Other
- select a option -
Field is required!
Occupation
Your Occupation
Field is required!
Designation
Field is required!
Are you satisfied with your current job?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Are you satisfied with your pension?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Are you satisfied with your current designation?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!
Are you satisfied with the financial welfare package?
  • - select a option -
  • Yes
  • No
- select a option -
Field is required!

Step 2: Section B

Stomach Pain
Field is required!
Headaches
Field is required!
Dizziness
Field is required!
Shortness of breath
Field is required!
Back Pain
Field is required!
Chest Pain
Field is required!
Fainting spells
Field is required!
Trouble sleeping
Field is required!
Pain in your arms, legs, or joints (knees, hips, etc.)
Field is required!
Menstrual cramps or other problems with your periods WOMEN ONLY
Field is required!
Feeling your heart pound or race
Field is required!
Pain or problems during sexual intercourse
Field is required!
Constipation, loose bowels, or diarrhea
Field is required!
Nausea, gas, or indigestion
Field is required!
Feeling tired or having low energy
Field is required!

Step 3: Section C

Little interest or pleasure in doing things
Field is required!
Feeling down, depressed, or hopeless
Field is required!
Trouble falling or staying asleep, or sleeping too much
Field is required!
Feeling tired or having little energy
Field is required!
Poor appetite or overeating
Field is required!
Feeling bad about yourself — or that you are a failure or have let yourself or your family down
Field is required!
Trouble concentrating on things, such as reading thenewspaper or watching television
Field is required!
Moving or speaking so slowly that other people could have noticed? Or the opposite — being so fidgety or restless that you have been moving around a lot more than usual
Field is required!
Thoughts that you would be better off dead or of hurting yourself in some way
Field is required!