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

Passport Surname (required)

Passport First Name (required)

Passport Second Name (required)

Name Called (required)

Telephone 1 (required)

Telephone 2

Email Address

Gender (required)
---MaleFemale

Age (required)

ID Number (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)

Relative's Contact Number (required)

Postal Address (required)

Physical Address (required)

How Many Scoan Visits Before Were Done? (required)

Golfshirt Size?
---SmallmediumlargeX largeXX largeXXX large

Which Would You Like? (required)
Spiritual EnrichmentHealingDeliverance

Explain Reason (required - max 300 characters)

Symptoms Experienced At The Moment? (required - max 300 characters)

Daily Living. How Does The Problem Affect Your In Your Daily Living? (required - max 300 characters)

Duration. How Long Do You Suffer From This Condition? (required - max 300 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)
YesNoNot Applicable (men)
If Yes, for how long?

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

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:

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