Register Patient
Identifiers
OpenMRS ID:
*
Patient Clinic Number:
National ID Number:
Demographics
Surname:
*
First Name:
*
Other Name(s):
Sex:
*
...
Male
Female
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
Age in Years:
*
Marital Status:
...
Married Polygamous
Married Monogamous
Divorced
Widowed
Cohabiting
Single
Occupation
...
Casual Labor
Driver
Employee
Farmer
Fisherman
Housework
Pre-school-aged child
School-age but not in school
Student
Professional
Retired
Small business owner
Trader
Vegetable seller
Unknown
Other
Education:
...
None
Primary School Education
Secondary School Education
College, University or Polytechnic
Deceased
Date of Death
*
Address
Telephone Contact:
Postal Address:
County:
Subchief name:
School/Employer Address:
District:
Province:
Location:
Sub-location:
Division:
Village/Estate:
Landmark:
House/Plot Number:
Next of Kin Details
Next of kin name:
Next of kin relationship:
Next of kin contact:
Next of kin address:
Encounter Location:
*
Encounter Location
*
...
Provider Name:
*
Provider's system-id:
*
Encounter Date
*