HIS2KRGOPD1											Republic of Namibia								Ministry of Health and Social Services
	Rev. 08/00
													Outpatient							Register
	Date (or	------- Fees Paid -------		-- Visit ---		Patient Name	Current Address/	Citizen-	Age	Sex		--------------- Parameters -------------------					Investigations			History/	Classification/	Advice/	Vacc.	Vit. A	Admit	Refer To	Seen	--------------- Provider ---------------		REMARKS
	Ser. No.			(       ONE)			Place	ship (if		(    ONE)										Symptoms/	Diagnosis	Treatment	Status	Given	This	(Name of	By
	For Date)	Amount	Coupon	1st	Fol.			NOT		M	F	Temp.	B/P	Pulse	Resp.	Weight				Signs			OK	(  =YES)	Facility	Facility)	Doctor	Name	Signature
			Number(s)		Up			Namibian)															(  =YES)		(  =YES)		(  =YES)
1																		1	1												1
2																		2	2												2
3																		3	3												3
4																		4	4												4
5																		5	5												5
6																		6	6												6
7																		7	7												7
8																		8	8												8
9																		9	9												9
10																		10	10												10
11																		11	11												11
12																		12	12												12
13																		13	13												13
14																		14	14												14
15																		15	15												15
16																		16	16												16
17																		17	17												17
18																		18	18												18