Encounter Form
Demographics
Patient Number
First Name:
Middle Name:
Last Name:
Gender:
...
Male
Female
Date Of Birth:
Village:
Encounter Details
Encounter Location:
*
Provider Name:
Provider Identifier:
*
Encounter Date:
*
Patient Vitals
Weight (kg):
Height (cm):
BMI (KG/M
2
)
*
Advice on weight loss, check Random Blood Sugar
Temperature (
o
C):
Pulse(bpm):