Izina / Name

Imyaka / Age

Igitsina / Sex

Male

Female

Umurwayi ni umunyeshuri / Patient is a student

Hitamo ishuri / Select school

Hitamo imwe / Select one Nyabirehe Rwinzovu Gatovu ibindi: nyamuneka sobanura / other: please specify

Izina ry'ishuri / School name

Icyiciro / grade

Hitamo imwe / Select one P1 P2 P3 P4 P5 P6 S1 S2 S3 S4 S5 S6

Umwuga / Occupation
Hitamo imwe / Select one Umukozi wo ku munsi / Day laborer Umuhinzi / Farmer Nyir'ubucuruzi / Business Owner Umukozi wo ku munsi / Professional Work abashomeri / Unemployed umunyeshuri / student

Aderesi / Address

Umurenge / Sector

Akagari / Cell

Umudugudu / Village

Inomero ya terefone / Phone Number

Umuryango / Family

umubare w'abagize umuryango / Number of family members

umubare w'abana mu muryango / Number of children in family

Umuvuduko w'amaraso / Blood Pressure

Systolique / Systolic

Diastolique / Diastolic

Uburemere (kg) / Weight (kg)

Uburebure (cm) / Height (cm)

Ubushyuhe (°C) / Temperature (°C)

Ikirego gikuru / Chief Complaint

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