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Kateto Joshua
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+260 777514418

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Ndola, Zambia.

Phone

+260 777514418

Email Address

info@gardenofgodtv.com

Welcome to The Garden of God International Ministries

Thank you for reaching out to us. We’re excited to have you visit us as our guest. To ensure a smooth and safe experience, please kindly provide the following information:

Visitor Information Form

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First Name

Last Name

Phone/Mobile

Gender

Male

Female

Email

Profession

Are you still working

Yes

No

Country of Birth

Country of Residence

1. Do you have any eye problems?

Yes

No

2. Do you have any ear problems?

Yes

No

3. Are you pregnant?

Yes

No

4. Do you have HIV?

Yes

No

5. Do you have any disabilities?

Yes

No

6. What is the nature of your sickness/problem?

7. How long have you been experiencing this issue?

8. What symptoms are you currently experiencing?

9. How does this issue affect your daily living?

10. Are you currently on medication?

Yes

No

11. Have you undergone any surgical operations?

Yes

No

12. Are you on a special diet?

Yes

No

13. Can you perform your daily duties normally?

Yes

No

14. Do you use any body braces?

Yes

No

15. Do you use any medical devices?

Yes

No

16. Do you have any open wounds?

Yes

No

17. Is any part of your body swollen?

Yes

No

18. Do you experience any body weakness?

Yes

No

19. Can you walk normally?

Yes

No

20. Do you limp?

Yes

No

21. Can you climb stairs without assistance?

Yes

No

Ndola, Zambia.
info@gardenofgodtv.com
+260 777514418

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