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Patient Information
Name:
Age:
Sex:
School:
Grade:
Phone Number:
Skin Check Up Station
Do you have any skin lesions or rashes currently?
Yego / Yes
Oya / No
How long have you had the rash?
< 1 month
1-3 months
3-6 months
> 6 months
Does not remember
Did you go to the health clinic?
Yego / Yes
Oya / No
Were you given Medication?
Yego / Yes
Oya / No
Why were you not given medicine?
Why did you not go to the health center
Submit