Name
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Date of Birth
Age
Email
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Home phone Number
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Mobile phone Number
Home Address
City
State/province
Postal/zip code
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Name of sickness
Location of sickness
How did the sickness started
When did the sickness started
Duration of sickness[Years]
What the sick person has not been able to do as a result of the sickness
Doctors report
Place of Registration
Date of Registration
time of Registration
Registration Secretary