Basic Encounter Form with at least 6 Early signs for Hypertension
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
Name of Health Center:
*
Encounter Location
*
...
Provider Name:
*
Provider system-id:
*
Encounter Date:
*
Early Symptoms/Signs of Hypertension
*
Severe headache
Fatigue
Vision problems
Chest pain
Labored breathing
Bloody urine
None