Gender --- Male Female
Country of Residence:
--- Aruba Afghanistan Angola Anguilla Åland Islands Albania Andorra United Arab Emirates Argentina Armenia American Samoa Antarctica French Southern Territories Antigua and Barbuda Australia Austria Azerbaijan Burundi Belgium Benin Bonaire, Sint Eustatius and Saba Burkina Faso Bangladesh Bulgaria Bahrain Bahamas Bosnia and Herzegovina Saint Barthélemy Belarus Belize Bermuda Bolivia, Plurinational State of Brazil Barbados Brunei Darussalam Bhutan Bouvet Island Botswana Central African Republic Canada Cocos (Keeling) Islands Switzerland Chile China Côte d'Ivoire Cameroon Congo, the Democratic Republic of the Congo Cook Islands Colombia Comoros Cape Verde Costa Rica Cuba Curaçao Christmas Island Cayman Islands Cyprus Czech Republic Germany Djibouti Dominica Denmark Dominican Republic Algeria Ecuador Egypt Eritrea Western Sahara Spain Estonia Ethiopia Finland Fiji Falkland Islands (Malvinas) France Faroe Islands Micronesia, Federated States of Gabon United Kingdom Georgia Guernsey Ghana Gibraltar Guinea Guadeloupe Gambia Guinea-Bissau Equatorial Guinea Greece Grenada Greenland Guatemala French Guiana Guam Guyana Hong Kong Heard Island and McDonald Islands Honduras Croatia Haiti Hungary Indonesia Isle of Man India British Indian Ocean Territory Ireland Iran, Islamic Republic of Iraq Iceland Israel Italy Jamaica Jersey Jordan Japan Kazakhstan Kenya Kyrgyzstan Cambodia Kiribati Saint Kitts and Nevis Korea, Republic of Kuwait Lao People's Democratic Republic Lebanon Liberia Libya Saint Lucia Liechtenstein Sri Lanka Lesotho Lithuania Luxembourg Latvia Macao Saint Martin (French part) Morocco Monaco Moldova, Republic of Madagascar Maldives Mexico Marshall Islands Macedonia, the former Yugoslav Republic of Mali Malta Myanmar Montenegro Mongolia Northern Mariana Islands Mozambique Mauritania Montserrat Martinique Mauritius Malawi Malaysia Mayotte Namibia New Caledonia Niger Norfolk Island Nigeria Nicaragua Niue Netherlands Norway Nepal Nauru New Zealand Oman Pakistan Panama Pitcairn Peru Philippines Palau Papua New Guinea Poland Puerto Rico Korea, Democratic People's Republic of Portugal Paraguay Palestine, State of French Polynesia Qatar Réunion Romania Russian Federation Rwanda Saudi Arabia Sudan Senegal Singapore South Georgia and the South Sandwich Islands Saint Helena, Ascension and Tristan da Cunha Svalbard and Jan Mayen Solomon Islands Sierra Leone El Salvador San Marino Somalia Saint Pierre and Miquelon Serbia South Sudan Sao Tome and Principe Suriname Slovakia Slovenia Sweden Swaziland Sint Maarten (Dutch part) Seychelles Syrian Arab Republic Turks and Caicos Islands Chad Togo Thailand Tajikistan Tokelau Turkmenistan Timor-Leste Tonga Trinidad and Tobago Tunisia Turkey Tuvalu Taiwan, Province of China Tanzania, United Republic of Uganda Ukraine United States Minor Outlying Islands Uruguay United States Uzbekistan Holy See (Vatican City State) Saint Vincent and the Grenadines Venezuela, Bolivarian Republic of Virgin Islands, British Virgin Islands, U.S. Viet Nam Vanuatu Wallis and Futuna Samoa Yemen South Africa Zambia Zimbabwe
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
--- 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?