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ABOUT GMC
GENERAL DESCRIPTION
SERVICES
FINANCIAL COVERAGE
EDUCATIONAL ACTIVITY
COLLABORATION
ADMISSION
VOLUNTEERS
Admission Form
Personal Information
Name:
Nationality:
Marital Status:
Single
Married
Birthday:
Sex:
Male
Female
Relatives:
Medical State
Fine
Not Fine
Chronic Diseases
Infectious Deseases
Mental Diseases
Allegry to any medicine ,food or smells? Specify:
Is he /she taking medication ?Kindly Specify:
Senses:(Describe)
HEARING:
Good condition
Bad condition
SENCE OF SMELL:
Good condition
Bad condition
SENSE OF TASTE
Good condition
Bad condition
SENSE OF TOUCH:
Good condition
Bad condition
SPEECH:
Good condition
Bad condition
IS HE /SHE CAPABLE OF WALKING?
Yes
No
Does he / she need any assistance ? ( walker- eye glasses-…)?
Financial Status
IS HE /SHE COVERED BY INSURANCE?
DOES HE /SHE OWN PRIVATE PROPERTY ,HAVE A BANK ACCOUNT, OTHER ?KINDLY SPECIFY :
RELATED TO THE PERSON FILLING IN THIS FORM :
NAME:
PHONE NO:
E-MAIL:
ADDRESS:
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