Visit Us – COJIM

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Name *

First

Last

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Nationality *

Age *

Do you have a sickness? *

Nature of the problem *

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 *

*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? *

Are you using any form of walking aid (crutch, stick, etc.) or wheelchair? *

Are you using any medical device to support your health condition? *

Are you limping? *

Do you still go about your daily activities normally without using any aids or assistance from other people? *

Can you walk normally/ climb stairs without assistance? *

Do you experience body weakness? *

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? *

Are you on a special diet as a result of your sickness/ problem? If so, please state details *

If so, please give 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 COJIM? *

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