Questionnaire Full Name Gender Male Female Age Nationality Country of Residence: Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cabo Verde Cambodia Cameroon Canada Central African Republic Chad Chile China Colombia Comoros Congo (Congo-Brazzaville) Costa Rica Croatia Cuba Cyprus Czech Republic (Czechia) Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast (Côte d'Ivoire) Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Macedonia Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Yemen Zambia Zimbabwe 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? If you are HIV positive, please indicate your status Yes No .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) How did you hear about The Holy Mountain Ministries Comments Send Questionnaire
