Welcome To HASANA!

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 ^*

Religion

Other

Language

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	Action

Email	Preferred Email	Action

Phone Type

Number ^*

Preferred Number

Email Address

Preferred Email

Emirate ^*

Community^*

Main District^*

District^*

Street Number

Street Name

Home Type

Home Type Name/Number

Apartment / Office Number

Building

Comments

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

To create Student Health File, please ensure that all required information is accurately entered in the fields under the following icon.

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^*

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Max file size 5 MB & Supported files [PDF, JPG, JPEG, PNG]

File Name	File Type	Category	Upload Date	Action

Company Name

Welcome To HASANA!

Symptoms

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

Attachments

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