Welcome To HASANA!

Patient Name

Subject ID

Baby of ^*

Last Name ^*

Mother's Emirates ID

Passport Number

Nationality

UID (Unified Identification Number)

Date Of Birth ^*

Gender ^*

Escort Information ^*

Name ^*

Contact Number ^*

First Name ^*

Middle Name

Last Name ^*

Full Name In Arabic ^*

Emirates ID

Emirates ID Expiry Date

Emirate

UID (Unified Identification Number)

Passport Number

Nationality ^*

Date Of Birth ^*

Age

Gender ^*

Marital Status ^*

Client Visa Status ^*

Request Patient Information Update ^*

Salama MRN (Epic ID)

Pregnant ^*

Additional ID (MRN)

Additional MRN Facility Name

Additional ID (MRN)	Additional MRN Facility Name

Allergy

Allergy Name	Severity	Status	Action
-	-	-

Disabilities

ICD Code Description	ICD Code	Status	Action
-	-	-

Visit Diagnosis

ICD Code Description	ICD Code	Status	Action
-	-	-

Problem List /Previous Visit Diagnosis

ICD Code Description	ICD Code	Status	Action
-	-	-

Phone Type

Number ^*

Preferred Number

Email Address

Preferred Email

Emirate ^*

Community^*

Main District^*

District^*

Address Detail

International Home Address

Country ^*

City^*

Immigration file number

Visa/residence expiry date

Is file valid or not ?

File Type

Residence File status

Permit File Status

Type of Sponsor

Sponsor name

Sponsor phone number/Sponsor mobile number

Sponsor Emirate

Sponsor License Issue Authority

Occupation

Contact Number

Qualification Level

Field Of Study

Degree Description

Choose Main Occupation ^*

Choose Specific Occupation Sector ^*

Name the company/authority the client is employed^*

Enter Other Employer^*

Choose Occupation^*

Other Occupation^*

Student/Educational Staff Details Type ^*

Educational Institute Type ^*

Is the educational institute located in Dubai? ^*

Education Type ^*

Education Facility Name ^*

Education Facility ^*

Other Education Facility ^*

Student Grade ^*

Mode of Learning ^*

Country ^*

Emirate ^*

Community ^*

Main District ^*

District ^*

Address Detail ^*

Does the patient live in a labor camp? ^*

Specify Labor Camp Location/Zone ^*

Enter Other Labor Camp Location ^*

Supervisor Name ^*

Supervisor Number ^*

Labor Camp Name ^*

Death Type / Manner of Death ^*

Death Date^*

Death Hour ^*

Death Category / Death Place ^*

Death Location / Hospital ^*

File Number ^*

Registered Emirate / Deceased Emirate ^*

Registered City / Deceased City ^*

Qaid Number or Registration Number ^*

Contributing Level

Direct Reason / Cause of Death

Diagnosis ^*

ICD Code ^*

Leading Reason / Cause of Death

Diagnosis ^*

ICD Code ^*

Actual Cause of Death

Diagnosis ^*

ICD Code ^*

Autopsy Performed? ^*

Other Significant Reason ^*

Information Source ^*

Port Transportation Information

Port Type Information ^*

Airline Name ^*

Flight Number ^*

Vessel Name ^*

Vessel IMO Number ^*

Car Number ^*

Country/City ^*

Port Occupation Information

Port Occupation Type^*

Occupation Location in the Vessel^*

Occupation Location in the Airport^*

Occupation Location in the Land Border^*

Company Name

Welcome To HASANA!

Client Registration Type

Mother Information

Client Information

File Info in Dubai Health Facility

Medical History

Allergy

Disabilities

Visit Diagnosis

Problem List /Previous Visit Diagnosis

Contact Details

Home Address

GDRFA

Occupation Information

Occupation Address

Labor Camp

Death Information

Ports Information