1. Name of Patient
2. Date of Birth of Patient?
3. Name of Parent/Guardian?
4. Contact of Parents/ Guardian?
Alternative Contact?
5. Type of Heart Condition?
6. Blood Group?
7. Weight of Patient?
8. Height of Patient?
9. Does the Patient have Echo Reports?
YES
NO
10. Place of Residence?
11. If location is not in or around Nairobi. Do you have accomodation in or around Nairobi?
YES
NO
12. Does the patient have an NHIF card?
YES
NO
If YES, Pleasae indicate ID no. of principal member?
13. Are you under any medication?
YES
NO
If YES,Please list Below
SUBMIT