Table of Contents
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Personal Information Sheet
Name/Naam _____________________________________ Mobile
_______________________
Passport # ______________________________________ Visa #
_________________________
______________________________________________________________________________
Allergies/Do NOT Give these medications, Allergies/Ausadhi na
dinus: ____________________
Medications I take daily, Ma dainik ausadhi khanchu: __________________________________
______________________________________________________________________________
Meds. I prefer if needed, Abasekta pareyo bhane linchu: ________________________________
Meds. I prefer if needed, Abasekta pareyo bhane linchu: ________________________________
In case of emergency: ____________________________________________________________
______________________________________________________________________________
Spouse, Pati/Patni, Son, Chora: ____________________________________________________
Daughter, Chori: ________________________________________________________________
Mother, Ama: __________________________________________________________________
Father, Buba/Bau/Baba: __________________________________________________________
Brother, Dhai/Bhai:
______________________________________________________________
Sister, Didi/Bhahini:
_____________________________________________________________
Friends, Sathiharu: ______________________________________________________________
______________________________________________________________________________