patient-form

[Ancentus]

Form Title: Patient Information Capture the following in the form. The field name is in curly braces.

1. EMS Patient ID {pat_ems_id}
2. First Name {pat_first_name}
3. Middle Name {pat_middle_name}
4. Last Name {pat_last_name}
5. Home Address {pat_address}
6. Home City {pat_city}
7. Home Country {pat_country}
8. Home Postal Code {pat_postal_code}
9. Gender {pat_gender}
10. Date of Birth {pat_dob}
11. Phone Number {pat_phone}
12. Next of Kin First Name {pat_nok_first_name}
13. Next of Kin Middle Name {pat_nok_middle_name}
14. Next of Kin Last Name {pat_nok_last_name}
15. Next of Kin Home Address {pat_nok_address}
16. Next of Kin Home City {pat_nok_city}
17. Next of Kin Home Country {pat_nok_country}
18. Next of Kin Home Postal Code {pat_nok_postal_code}
19. Next of Kin Phone Number {pat_nok_phone}
20. Next of Kin Relationship {pat_nok_relationship}