Indian Association of Muscular Dystrophy

INDIAN ASSOCIATION OF MUSCULAR DYSTROPHY

1. Name ……………………………………Date ……………………... 2. S/O, D/O, W/O. …………………… Date of Birth ………………… 3. Registration No.(Office Use Only).. ………………………………… 4. Address:- ……………………………………………………………. …………………………………………………………… ………………………..Pin Code ………………………. Colour 5. Gender (Male/Female) ……………………………………………….. Pasport 6. Telephone No. 1) …………………2)………………3)……… ……... Size Photo 7. Type Of Muscular Dystrophy :- A) EXION ………………………………………………...... B) RESULT ……………………………………………………..

6. Marital Status :- Un Married / Married / Widower / Widow. 7. Email Id ………………………………………………………………. 8. Education Uneducated / Primary / Middle / Sec. Secondary / Graduate/

Other ………………………………………………………………….. 9. Occupation …………………………………………………………….. 10. Family Status:- Father Mother Brother

Sister Other

11. Monthly Income …………………………………………………………. 12. Ambulatory/ NON Ambulatory …………………………………………. 13. Stand / NON Stand ………………………………………………………. 14. Wheel Chair ……………………………………………………………… A) Noramal

B) Poweer

15. Can you take help for any person to daily work ? If Yes Then Who Father Mother Brother

Sister Other

Note:- Send your two passport size Photo With this form. If you have another information use another paper.