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