Plan Type

SSPH

BMPHS

Male

Female

Local Government Area

Aninri

Awgu

Enugu East

Igbo Etiti

Igbo Eze North

Igbo Eze South

Isi Uzo

Nkanu East

Nkanu West

Nssuka

Oji River

Udenu

Udi

Uzo Uwani

Status

Single

Married

Others

Employed

Full-time Student

Part-time Student

Beneficiary Genotype

AA

AS

SS

SC

Blood Group

O+

O-

A+

A-

B+

B-

AB+

AB-

Pre-Existing Condition

Hypertension

Glaucoma

Asthma

Cataract

Diabetes

Heart Disease

Tuberclosis

Cancer

Duodenal Ulcer

Peptic Ulcer

Kidney Disease

Hiv/Aids

Fibroid

Sickle Cell

Epilepsy

Arthritis

Spouse Date of Birth

Spouse Sex

Male

Female

Status

Employed

Full-time Student

Part-time Student

Spouse Genotype

AA

AS

SS

SC

Spouse Group

O+

O-

A+

A-

B+

B-

AB+

AB-

Pregnant/Vulnerable

Pregnant

Y

N

Vulnerable

 

Y  

N  

Disability

Visual Impairment/Seeing

Hearing Impairment

Mobility

Daily Life Activity

Communication and social Function

Intellectual and Learning Difficulty

Behavioural and Psychological Difficulty

Fits and Seizures

Ever had Surgery

Y

N

Year of Surgery

I hereby declare that all the informtion provided are all true to the best of my knowledge, and that I have not withheld any information.
I agree to abide by the terms and conditions of the Enugu State universal health coverage scheme (ESUHCS).

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