Age Gender Male Female Nationality Country of Residence Profession Your Email Phone number Relatives Name Relatives Phone Number 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 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 Yes put the names Below How did you hear about Joy of Salvation Ministry (JOSMI) Do you require accommodation in a hotel? If yes state the type More Comments