Register for Covid-19 Relief Program

Disease *

Full Name *

Phone Number *

E-mail *

Address

Age

Gender
Male Female

Please put yes/no for the following
If yes, please classify as mild/ troublesome and mention duration

Head ache

Neck Pain

Upper back ache

Lower back ache

Pain at any other site in the body – please specify site

Breathlessness

Abdominal pain or discomfort

Heart burn

Disturbed sleep

Feelings of anxiety/ stress/ tension

Feelings of sadness/ depression

Constant fatigue

Diabetes

High blood pressure

Thyroid disease

Heart disease

Overweight

Any other

Please send a list of your medicines with dose

Breathing out duration

Breath retention capacity

Flexibility score

Message