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Name
   
 
 
 
Age
   
 
 
 
Gender
 
Male
 
Female
 
 
 
Contact Details (Telephone no./Locality) :
   
 
 
 
Religion
 
Hindu
 
Muslim
 
Christian
 
Sikh
 
Jain
 
Jew
 
Other
 
 
 
 
Caste :
   
 
 
 
What is your age-group?
 
13-19
 
20-24
 
25-34
 
35-44
 
45-54
 
55 or above
 
 
 
Are you married?
 
Yes
 
No
 
 
 
How many members are there in your family?
 
2
 
3
 
4
 
5
 
6 or more
 
 
 
How many children do you have, if any?
 
1
 
2
 
3
 
4 or more
 
 
 
How many children do you have, if any?
 
1
 
2
 
3
 
4 or more