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Country of Residence
- Country -
Afghanistan
Albania
Algeria
Andorra
Angola
Anguilla
Antigua & Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia & Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
China - Hong Kong / Macau
Colombia
Comoros
Congo
Congo, Democratic Republic of (DRC)
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
French Guiana
Gabon
Gambia, Republic of The
Georgia
Germany
Ghana
Great Britain
Greece
Grenada
Guadeloupe
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Israel and the Occupied Territories
Italy
Ivory Coast (Cote d'Ivoire)
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea, Democratic Republic of (North Korea)
Korea, Republic of (South Korea)
Kosovo
Kuwait
Kyrgyz Republic (Kyrgyzstan)
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar/Burma
Namibia
Nepal
New Zealand
Nicaragua
Niger
Nigeria
North Macedonia, Republic of
Norway
Oman
Pacific Islands
Pakistan
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovak Republic (Slovakia)
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Tajikistan
Tanzania
Thailand
Netherlands
Timor Leste
Togo
Trinidad & Tobago
Tunisia
Turkey
Turkmenistan
Turks & Caicos Islands
Uganda
Ukraine
United Arab Emirates
United States of America (USA)
Uruguay
Uzbekistan
Venezuela
Vietnam
Virgin Islands (UK)
Virgin Islands (US)
Yemen
Zambia
Zimbabwe
Your Relatives Information
Salutation
Mr.
Ms.
Mrs.
Br.
Sis.
Dr.
First Name
Last Name
Gender
Male
Female
Phone Number
Relative's Phone Number
Email
*
Relative's Email
Your Medical Information
Are you having any sickness?
Yes
No
Nature of Problem
Duration of Problem
Any Medication
Please include images of any medication currently taken
Leave blank if no answer
How has the problem affected your life
Have you been Hospitalized ?
Yes
No
If yes, Please include your medical report.
Leave blank if no answer
HIV Status
- - - - - - -
Positive
Negative
Not sure
Are you using any form of brace?
Yes
No
Are you using any form of walking aid (crunch, stick, etc.) or wheelchair?
- - - - - -
Crunch
Stick
Wheelchair
Other
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
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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)
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