Questionnaire Full Name Gender Male Female Age Nationality Country of Residence: Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verde Central African Rep Chad Chile China Colombia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar, {Burma} Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia Saint Vincent & the Grenadines Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe Profession Your Email Phone 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 None HIV1 HIV2 HIV3 *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? YES NO Are you using any form of walking aid (crutch, stick, etc.) or wheelchair? YES NO Are you using any medical device to support your health condition? YES NO Are you limping? YES NO Do you still go about your daily activities normally without using any aids or assistance from other people? YES NO Can you walk normally/ climb stairs without assistance? YES NO Do you experience body weakness? YES NO 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 Send Questionnaire
