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Visit CLSOTWW Form

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Medical Details Please state the nature of the problem * Upload a picture of your condition

For how long have you been experiencing this problem? * List all medications you are taking * How has this problem affected your daily living? * Have you ever been hospitalized? If yes, where? * If you are HIV positive, please indicate your status * Are you using any form of walking aid (e.g., crutches, wheelchair)? * Are you using any medical device to support your condition? * Are you using any breathing support? * Do you participate in daily activities without assistance? * Are you limping? * Can you walk/climb stairs without assistance? * Do you experience body weakness? * Have you had surgery or therapy related to the problem? If yes, explain. * Is any part of your body swollen? If yes, where? * Do you have any open wounds? If yes, where? * Are you on a special diet due to your illness/problem? * Do you have any other illnesses or conditions? * Do you intend to come alone or with someone? * How did you hear about The Christ Love Synagogue Of The Whole World (CLSOTWW)? * Comments *