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Name

Age:

ID Number:

Contact Number:

E-mail

Any chronic medicine:

Name Medication:

Hypertension Hypertension Yes No

Sugar Diabetes Sugar Diabetes Yes No

Asthma Asthma Yes No

Allergies Allergies Yes No

Athritis Athritis Yes No

TB/HIV TB/HIV Yes No

Any Supplements:

Name Supplements:

1) Previous Hospital Admission/when:

2) Previous Hospital Admission/when:

How many Children

Cesarian or Natural Birth:

1 )Any previous surgery:

2) Any previous surgery:

Do you smoke: Do you smoke: Yes No

Do you drink alcohol: Do you drink alcohol: Yes No