Patient Number

First Name:

Middle Name:

Last Name:

Gender: ... Male Female

Date Of Birth:

Village:

Encounter Location:*

Provider Name:

Encounter Date:*

Weight (kg):

Height (cm):

BMI (KG/M²) *

Temperature (^oC):

Pulse(bpm):

Joint Stiffness

Joint Swelling

Joint Pain

Lateral Joint Line Tenderness of knee

Fatigue

Fever