Encounter Form With Checkboxes
Demographics
Patient Number
First Name:
Middle Name:
Last Name:
Gender:
...
Male
Female
Village:
Date Of Birth:
Encounter Details
Encounter Location:
*
Provider Name:
*
Provider system-id:
*
Encounter Date:
*
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