Encounter Form With Checkboxes
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):
Temperature (
o
C):
Pulse(bpm):
Signs and Symptoms
Symptoms related to the head, eyes, ears, neck and throat
Hearing Difficulties
Ear Discharge
Oral Sores
Thrush
Vision Difficulties
Nasal Discharge
Swallowing Difficulties
No Symptom