Questionnaire

Full Name

Gender

Age

Nationality

Country of Residence:

Profession

Your Email

Phone

Relatives Name

Relatives Phone

Relatives Email

Are you having any sickness?

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

*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.Are you using any form of brace?

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

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

Are you limping?

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

Can you walk normally/ climb stairs without assistance?

Do you experience body weakness?

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)

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

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