SCD Registry | Register as PLWSCD

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Registry details

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ID

Date*

Date and time when data was entered

Name*

Name of patient testing HBV

Phone Number*

Patients phone number or guardians phone number

Date of Birth*

patients date of birth

Age*

age of patient

Gender*

Patients gender

Male
Female

Province*

kenyan region

County*

county where patient comes from

Subcounty*

subcounty where patient comes from

Village

village where patient comes from

Nearest landmark

nearest church or school where patient lives

Subject occupation*

if it is a child or student to be indicated here

Medical cover*

does the patient have medical cover

Yes
No

Medical cover type

specific medical cover

Mode of enrolment

how the patient was enrolled in the medical cover and how it is paid for

Is the cover currently active and paid for?

active medical cover

None
Yes
No

Ever done SCD confirmation test

Ever done scd confirmation test

None
Yes
No

Test type*

type of test done to determine hbv of patient

Any relative(s) ever diagnosed with sickle cell disease:*

Yes
No

If YES, how many

how many relatives have scd in your family history

Where do you attend clinic?

Where would you like to attend clinic?

Ever received any of the following vaccines?

Check any medication you are using

Have you ever received Genetic Counselling?

None
Yes
No

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