AVON HMO Registration

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Health Plan: *

State: *

LGA: *

Hospital Name: *

Child's account No: *

Surname: *

First name: *

Other names: *

Date of Birth: *

Gender: *

Child's town: *

Child's home address: *

Parent/Guardian's name: *

Parent/Guardian's Phone No: *

State:

Enrollee's' Phone No: *

Parent/Guardian's Email: *

Child's passport photograph (upload a picture in format jpg, png, bmp | maximum filesize is 5mb): *

Marital Status: *

Next Of Kin: *

Next Of Kin Address: *

Next Of Kin Phone No:*

	Yes	No
Chest pain / Angina or heart attack?
High blood pressure (hypertension)?
Lung/respiratory condition e.g. asthma, bronchitis, emphysema?
Stomach / bowel disorder e.g. peptic ulcer or diverculities or ulcerative calitis?
Urinary or kidney disorder e.g. kidney stones, urine incontinence?
Recurrent urinary tract infections or any requiring dialysis?
Muscle / bone or joint disorder e.g. bone fractures, osteoporosis, gout or arthritis?
Diabetes which is controlled by insulin drugs and / or diet?
Prostrate disorder?
Epilepsy or seizures?
Depression or schizophrenia or bipolar or other mental health conditions or drug or / and alcohol dependency?
Blood disorder e.g. sickle cell anemia or thalassemia or G6PD?
Disease of the eye or nose or throat lasting longer than six month
If yes, please give details *
Cancer that has been partially or totally treated?
Congenital abnormalities?

Are you pregnant?
When was your last Pregnancy?
Any Complications post delivery?
If yes, please select any that pertains to you:?
Any history of irregular menstrual cycle?
Any history of gynecologic procedures or surgery?
If yes, please give details *

Has your enrollee tested positive for HIV/AIDS?
Has your enrollee experienced any of the following unexplained weakness, weight loss, diarrhea, skin lesions or enlarged nymph nodes?
Does your enrollee take any prescription medications for periods longer than one month?
If yes, what drugs*
Has there been any change in any of the prescription dosage/s?
If yes, what drugs*
Has your enrollee received any new prescription, investigation or new medical consultation in the last 6 months?

Medical conditions