1. Last name:

(_) Mohammed (_)Ahmed(_) Ali (_) Khaled(_) Dot no

(Check karet bUxa)

3. Age:

(_) Less than phipty (_) Greater than phipty (_) Dot no

(Check karet bUxA)

4. Sex: ____ din mai ek baar _____ do baar _____ raat bhar

male (___) ya female (__)

5. Chappal Size: ____ Lepht ____ Right

6.Occupason:

(_) Politison (_) Doodhwala (_) Pehelwaan (_) House wife! (! ! _) Un-employed

(Check karet box)

7. Number of children libing in the household: ___

8. Number that are yours: ___

9. Mather name: _______________________

10. Phather Name: ____________________ (If not no,leave blank)

11. Ejjucason: 1 2 3 4 (Circle highest grade completed)

12. Dental rekard:

(_) Ellow (_) Berownish-ellow (_) Berown (_) Belack (_) Other -__________ Give egjhakt color

(Check karet bUXA)