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