VISIT US - QUESTIONNAIRE

VISIT US QUESTIONNAIRE

ROAD MAP TO JESUS INTERNATIONAL MINISTRIES

To visit The Roadmap to Jesus International Ministry, kindly complete the questionnaire provided and submit it. Your detailed responses will help us effectively handle your request. Most communication regarding your visit will be conducted via email and WhatsApp. Please await confirmation from us before making any travel plans.

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Questionnaire Form

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Name *

Prénom

Nom

Gender

Date of Birth

Nationality

Country of Residence

Profession

Email *

Relative Name *

Relative Numbers

Relative Email *

Are you having any sickness?

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 or have taken due to this problem or condition.

How has the problem or condition affected your daily living?

Have you ever been hospitalized? If yes 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 a 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 or 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 yes, please give details

Is any part of your body swollen? If yes, where?

Do you have any open wound? If yes, where?

Are you on a special diet as a result of your sickness or problem? If yes, please state the details

Do you have any other sickness or problems? If yes, 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 Roadmap to Jesus International Ministry?