Registration Form – CV Patient Site

Patient Number/ចំនួន អ្នកជម្ងឺ*

Please enter a number from 0 to 6000.

Gender / ភេទ*

Are you pregnant/អ្នកមានផ្ទៃពោះ?

Full Name | ឈ្មោះពេញ ៖*

Age/អាយុ

Patient has TB | អ្នកធ្លាប់មានជំងឺរបេងដែរទេ?*

Contact Phone Number/s (If any)*

Present Address/From:

Province/ខេត្ត*

Phnom Penh Districts*

Banteay Meanchey Districts*

Battambang Districts*

Kampong Cham Districts*

Kampong Chhnang Districts*

Kampong Speu Districts*

Kampong Thom Districts*

Kampot Districts*

Kandal Districts*

Koh Kong Districts*

Kep Districts*

Kratié Districts*

Mondulkiri Districts*

Oddar Meanchey Districts*

Pailin Districts*

Preah Vihear Districts*

Pursat Districts*

Prey Veng Districts*

Ratanakiri Districts*

Siem Reap Districts*

Sihanoukville Districts*

Stung Treng Districts*

Svay Rieng Districts*

Takéo Districts*

Tboung Khmum Districts*

Village/ភូមិ*

Commune/ឃុំសង្កាត់*

Reason for visit | មូលហេតុមកថ្ងៃនេះ*

Please be descriptive on why has the patient come here today. This helps the Doctors ask the right questions during their evaluation.

Date