Demographics Update Form
Names
Family Name:
*
Given Name:
*
Middle Name:
Mother's Name:
Will update names?
Add Names
New Family Name:
*
New Given Name:
*
New Middle Name:
New Mother's Name:
Address
County:
Location:
Sub-location:
Village:
Phone Number:
Will update Address?
Add Address
County:
Location:
Sub-location:
Village:
Phone Number:
Identifiers
AMRS Universal ID:
*
Add Identifiers:
Identifier Type:
...
AMRS Universal ID
AMRS Medical Record Number
CCC Number
HCT ID
KENYAN NATIONAL ID NUMBER
MTCT Plus ID
MTRH Hospital Number
Old AMPATH Medical Record Number
pMTCT ID
Enter Identifier:
Confirm Identifier:
Sex:
*
...
Male
Female
Will change Sex?
Update Sex:
*
...
Male
Female
Birthdate
*
Will change Birth Date?
Will Record Date of Birth...
*
...
By Birth-date
By Age
Select New Birthdate
*
Is this birthdate an estimate?
*
...
Yes
No
How old are you in Years
*
Encounter Location:
*
Encounter Location
*
...
Provider Name:
Provider's system-id:
*
Encounter Date
*