If you would like to visit The Synagogue, Church Of All Nations, please complete the questionnaire and submit it. Please fill out the questionnaire in detail. This will enable us to deal with your request efficiently. All further correspondence with the church regarding your visit will be done through email. Please note, you must wait for confirmation of your visit from us before making any travel arrangements.

*All HIV patients need to come with their most recent original printed HIV confirmatory report when their visit is confirmed. Please note that no screening report will be accepted, only a confirmatory report that clearly states that this patient is HIV I, II OR III positive, and it must be typed on the hospital’s letterhead. It must be a government recognized hospital in your country. You cannot come without the correct medical report.

First Name:

Last Name:

Gender:

Age:

Nationality:

Country of Residence:

Profession:

Phone:

Email:

Relatives Name:

Relatives Phone:

Relatives Email

Are you having any sickness?

Yes No

Please state the nature of the problem you are having and all the symptoms. Please specify in detail:

For how long have you been experiencing this problem?

List all the medications you are taking/ have taken due to this problem/ condition:

How has the problem/ condition affected your daily living?

Have you ever been hospitalized? If so when?

If you are HIV positive, please indicate your status:

N/A HIV 1 HIV 2 HIV 3

Are you using any form of brace?

No Yes

Are you using any form of walking aid (crutch, stick, etc.) or wheelchair?

No Yes

Are you using any medical device to support your health condition?

No Yes

Are you limping?

No Yes

Do you still go about your daily activities normally without using any aids or assistance from other people?

No Yes

Can you walk normally/ climb stairs without assistance?

No Yes

Do you experience body weakness?

No Yes

Have you had any surgery or other therapy as a result of the problem/ condition? If so, please give details.

Is any part of your body swollen? If so, where?

Do you have any open wound? If so, where?

Are you on a special diet as a result of your sickness/ problem? If so, please state details:

Do you have any other sickness or problems. If so, please list all symptoms, treatments and medications:

Do you intend to come alone or accompanied? (If you will be accompanied, please ask each of those with you to also submit this questionnaire, indicating in the comments section that they intend to come with you

Alone Accompanied

How did you hear about The Synagogue, Church Of All Nations?

Comments: