Basic Encounter Form with at least 6 Early signs for Diabetes
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:
*
Symptoms/Signs of Diabetes
*
Urinating Often
Blurred Vision
Numbness in Hands
Numbness in feet
Feeling very thirsty
Extreme Fatigue
None