Step 1 – General Questionnaire

Application Form – Questionnaire for South African Applicants

Please Note

IT IS VERY IMPORTANT THAT YOU PROVIDE US WITH ACCURATE INFORMATION CONCERNING YOUR HEALTH AND REASON FOR VISIT BECAUSE THE WAY AND MANNER WE RECEIVE FROM GOD ALMIGHTY MATTERS.

    Title (Mr, Mrs, Ms, Prof etc) (required)

    Passport Surname (required)

    Passport First Name (required)

    Passport Second Name (required)

    Name Called (required)

    Telephone 1 (required e.g. 082 412 8876)

    Telephone 2 (e.g. 012 311 1483)

    Email Address (accurate spelling is important)

    Gender (required)

    Age (required)

    Birthday (required)

    Country (required)

    Passport Number (required)

    Profession (required)

    Do You Currently Work? (required)
    YesNo

    Town (required)

    Medical Aid Name

    Medical Aid Number

    Relative's Contact Name (required state name and how related)

    Relative's Contact Number (required)

    Postal Address (required)

    Physical Address (required)

    How Many Scoan Visits Before Were Done? (required)

    Golfshirt Size?

    Which Would You Like? (required)
    Spiritual EnrichmentHealingDeliverance

    Explain Reason (required - max 200 characters)

    Symptoms Experienced At The Moment? (required - max 200 characters)

    Daily Living. How Does The Problem Affect Your In Your Daily Living? (required - max 200 characters)

    Duration. How Long Do You Suffer From This Condition? (required - max 200 characters)

    Eyes. Do You Have Problems With Your Eyes, And Or Blindness? (required)
    YesNo

    Ears. Do You Have Any Problems With Your Ears, And Or Deathless? (required)
    YesNo

    Hiv (required)
    YesNo (required)

    Daily Activities.? Can You Do Daily Activities Without Assistance From People? (required)
    YesNo

    Walk? Can You Walk Normally Without Difficulty Or Without The Use Of Walking Aid Or Assistance
    From People? (required)
    YesNo

    Stairs Can You Climb The Stairs Without The Use Of Walking Aids Or Assistance From People (required)
    YesNo
    Limp (required)
    YesNo

    Brace/Aid? Are You Using Any Form Of Brace, Walking Aid (Crutch/Stick) Or Wheelchair? (required)
    YesNo

    Medical Device? Are You Using Any Medical Device Due To Your Health Condition? (required)
    YesNo

    Do you have an open wound? State Yes/No. If Yes please provide more details.(required)

    Swollen. (required)
    YesNo
    Weakness. (required)
    YesNo

    Did you had an operation? State Yes/No. If Yes please provide more details.(required)

    Are you on a diet? State Yes/No. If Yes please provide more details.(required)

    Medication. Are You On Medication? State Yes/No. If Yes please state for which health condition you use medication and provide the details eg: injections or tables (required - max 300 characters)

    Are you pregnant? (required)

    In which city do you want to be screened? (required)

    Did you apply with a previous group coordinator within the last 3 months (If so, with whom. What was the outcome?)

    DO YOU HAVE THE FOLLOWING CONDITIONS?

    Acid Reflux Disease (GERD)AllergiesAttention Deficit Disorder (ADHD/ADD)Alzheimer's DiseaseAnorexia NervosaAspergers SyndromeAutismAcneAntisocial Personality DisorderAltitude SicknessAndropauseArthritisAsthmaAvoidant Personality DisorderBack PainBaldnessBipolar Disorder (BD)Body Dysmorphic Disorder (BDD)Borderline Personality Disorder (BPD)Breast CancerBrain InjuryBurnsBad Breath (Halitosis)BedwettingBladder CancerBleedingBone CancerBrain CancerBrain TumorsBronchitisBursitisCancerCanker Sores (Cold Sores)Carpal Tunnel Syndrome (CTS)Celiac DiseaseCervical CancerCholesterolChronic Obstructive Pulmonary Disease (COPD)Colon CancerCongestive Heart Failure (CHF)Cradle CapCrohn's DiseaseDandruffDeep Vein Thrombosis (DVT)DehydrationDependent Personality DisorderDepressionDiabetesDiaper RashDiarrheaDisabilitiesDiverticulitisDown SyndromeDrug AbuseDysfunctional Uterine Bleeding (DUB)DyslexiaEar InfectionsEar ProblemsEating DisordersEczemaEndometriosisEnlarged ProstateEpilepsy (Seizure)Erectile Dysfunction (ED)Eye ProblemsFibromyalgiaFractureFrecklesFluFibroidsGallbladder DiseaseGallstonesGeneralized Anxiety Disorder (GAD)Genital HerpesGenital WartsGlomerulonephritis (Nephritis)GonorrheaGoutGum DiseasesGynecomastiaHead LiceHeadacheHearing LossHeart AttacksHeart DiseaseHeartburnHeat StrokeHeel PainHemorrhageHemorrhoidsHepatitisHerniated DiscsHiatal Hernia (Hiatus Hernia)Histrionic Personality DisorderHIV/AIDS - If you are HIV + please indicate the type (HIV I/II/III):HivesHyperglycemia (High Blood Sugar)Hyperkalemia (High Potassium)Hypertension (High Blood Pressure)HyperthyroidismHypothyroidismInfectious DiseasesInfectious Mononucleosis (Glandular Fever)InfluenzaInfertilityInsulin Dependent Diabetes Mellitus (IDDM)Iron Deficiency AnemiaIrritable Bowel Syndrome (IBS)Irritable Male Syndrome (IMS)ItchingJoint PainJuvenile DiabetesJuvenile Rheumatoid Arthritis (JRA)Kidney DiseasesKidney Stones (Renal Calculi)LeukemiaLiver Cancer - Hepatocellular carcinoma (HCC)Lung CancerMad Cow DiseaseMalariaMelena (Blood in Stool)Memory LossMenopauseMesotheliomaMigraineMiscarriagesMucus In StoolMultiple Personality DisorderMultiple Sclerosis (MS)Muscle CrampsMuscle FatigueMuscle PainNail BitingNarcissistic Personality DisorderNeck PainObesityObsessive Compulsive Disorder (OCD)Osteoarthritis (OA)OsteomyelitisOsteoporosisOvarian CancerPainPanic AttackParanoid Personality DisorderParkinson's Disease (PD)Penis EnlargementPeripheral Artery Disease (PAD)Personality DisordersPeptic UlcersPervasive Developmental Disorder (PDD)Peyronie's DiseasePhobiasPink Eye (Conjunctivitis)PolioPneumoniaPost Nasal DripPost Traumatic Stress Disorder (PTSD)Premature BabyPremenstrual Syndrome (PMS)PropeciaProstate CancerPsoriasisReactive Attachment Disorder (RAD)Renal FailureRestless Legs Syndrome (RLS)Rheumatoid Arthritis (RA)Rheumatic FeverRingwormRosaceaRotator CuffScabiesScarsSciaticaSevere Acute Respiratory Syndrome (SARS)Schizoid Personality DisorderSchizophreniaSexually Transmitted Disease (STD)Sinus InfectionsSkin CancerSkin RashSleep ApneaSleep DisordersSmallpoxSnoringLow Sperm CountNo Sperm CountSocial AnxietyStaph Infection (MRSA)Stomach CancerStrep Throat (Sore Throat)Sudden Infant Death Syndrome (SIDS)SunburnSyphilisSystemic Lupus Erythematosus (SLE)Tennis ElbowTermination of Pregnancy (Abortion)Testicular CancerTooth DecayTrisomy SyndromeTuberculosis (TB)Blocked TubesUlcersUrinary Tract Infection (UTI)Varicose VeinsVertigoWartsWilliams SyndromeYeast Infection (Candidiasis)Yellow FeverMental Health and Mental DisordersRare DiseasesList of Common Infectious DiseasesList of Genetic Disorders and DiseasesList of Mental Disorders - Types of Mental IllnessMental IllnessesList Of PhobiasDifferent Types of Mood DisordersTypes of ArthritisOrthopaedic DisordersTypes of Brain TumoursDifferent Types of LeukemiaTypes of Skin CancerDifferent Types of WartsDifferent Types of Bone Fractures

    If you have any other illness, please state/list below:

    NB. Click the "SUBMIT" button once. You must then, and will get a message that it was submitted successfully.
    Depending on your internet connection there might be a slight delay.

    If you did not get the message that your application was submitted, it imply that it was not going through. It might be because of your internet or your phone settings. We advice you go to Internet Cafe to assist you with the application.