PATIENT REGISTRATION
1.Personal Details
Type :
Patient Number :
Full Name :
First Name :
Middle Name :
Last Name :
Address :
Age :	years months
Date of birth (dd/mm/yyyy):
Place of birth :
New IC:
Old IC:
Race:
Religion:
Sex:
Tel No(H):
Tel No 2:
Tel No 3:
E-mail:
2.Financial Details
Panel or private:
Panel ID:
Panel/Employer:
3.Physical Details
Eye colour:
Skin colour:
Hair colour:
Blood type:
Picture file:
Medical history :
Allergies :
Drugs interaction :
Asthmatic (0=No, -1=Yes) :
Low blood press. :
High blood press. :
High cholesterol :
Smoking :
Alcohol problem:
Diabetic :
Heart problems :
Insurance company:
GL period from:
GL period to:
Blacklisted? :