JESUS CHRIST HEALING CENTER SICK PERSON’S PROFILE FORM

Name *

Email Address *

Age

Gender *MaleFemale

Country

Nationality

Hometown

Name of Sickness *

Description of Sickness *

How did the sickness started? *

Medical Doctor, Man of God, Herbalist, Traditional healer, Malam/Islamic healer, Witch doctor, Fetish priest, spiritualist, others

others

HospitalClinicChurchCrusadeTemplePrayer -CampHealing CenterShrineForestRiver sideSacred placeothers

others

When did the sickness started? *

What were you asked to do when you visited any of these persons or places? *

Duration of sickness[Years] From: *

to *

Medical Doctor’s report *

What the sick person has not been able to do as a result of the sickness *

Date *