Gender *MaleFemaleAge *Nationality *Country of Residence *Profession * Your Email *Phone *Relatives Name *Relatives Phone *Relatives Email *Are you having any sickness? *YesNoPlease state the nature of the problem you are having and all the symptoms. Please specify in detailFor how long have you been experiencing this problem?List all the medications you are taking/ have taken due to this problem/ conditionHow has the problem/ condition affected your daily living?Have you ever been hospitalized? If so when?If you are HIV positive, please indicate your statusHIV1HIV2HIV3*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? *YesNoDo you experience body weakness? *YesNoAre you using any form of walking aid (crutch, stick, etc.) or wheelchair? *YesNoAre you using any medical device to support your health condition? *YesNoAre you limping? *YesNoDo you still go about your daily activities normally without using any aids or assistance from other people? *YesNoCan you walk normally/ climb stairs without assistance? *YesNoHave 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 detailsDo you have any other sickness or problems. If so, please list all symptoms, treatments and medicationsDo 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) *AloneAccompaniedComments
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