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nipithë ėthë dayen
address [where do you live at?]
Recording:
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wgetthda nė gdaw
are you a veteran?
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bégednëgét
authorized by [the one who allows things]
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penothé
child
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nithë ngom ė yawêk
date [what is it today?]
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nithëwpi ga ndadzëyen
Date of birth [when were you born?]
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wénithë da shëgnongot
emergency contact [who should be called?]
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nipithë ėthë miktthéwiyen
employer [where do you work at?]
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nipithë ėthë miktthéwiyen
employment [where do you work at?]
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wgetsimen
h/s parent(s)
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wénithë wa wabthegazet
patient [who will be seen?]
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nithë ė zhnëkazyen
patient name [what are you called?]
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wzhebyé’en gbiwapkogdaswen
phone number [write your phone number]
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Pëgėgnenimshkëkiwgëmëk
Pokagon Health Services
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nithë ėnwémet
relationship to patient [how are you related to h/s?]
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yazhdéyakwpi’gén
signature of patient [make your mark]
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maktthéwit wdazhdéyakwpi’gën
signature of PHS staff [signature of worker]
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nipithë ėthë dbéndagwzëyen
Tribal affiliation [where are you enrolled at?]
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ga wawabdêk
witness [the one who watched]
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