First Name
Last Name
Gender
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Male
Female
Age
Nationality
Country of Residence:
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?
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 Prophet W Magaya (PHD
Ministries)?
Comments
Send Questionnaire