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Patient Registration Form
Please fill in all the required details to register a new patient
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Section
PATIENTS HEALTH DETAILS
First name:
*
Middle name:
Last name:
*
Gender:
Select gender
Male
Female
Other
Date of birth:
*
Cell number:
*
Id number:
Section
Medical Background
Are you presently under a physician's care? YES / NO
YES
NO
Do you use any medicine regularly? YES / NO
YES
NO
Have you ever had any serious illness /operation? YES /NO
YES
NO
Section
Have you ever had any of the following diseases and for how long?
DISEASE
EVER HAD IT
HOW LONG
Jaundice / liver disease
YES
NO
How long - Jaundice / liver disease
Heart disease
YES
NO
How long - Heart disease
Diabetes
YES
NO
How long - Diabetes
Hypertension
YES
NO
How long - Hypertension
Asthma / respiratory
YES
NO
How long - Asthma / respiratory
Bleeding disorder
YES
NO
How long - Bleeding disorder
Hepatitis
YES
NO
How long - Hepatitis
HIV / AIDS
YES
NO
How long - HIV / AIDS
Tuberculosis
YES
NO
How long - Tuberculosis
Epilepsy
YES
NO
How long - Epilepsy
Cancer (past or present)
YES
NO
How long - Cancer (past or present)
Other serious illness
YES
NO
How long - Other serious illness
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