Register for CSO Wellness Programme
Status
Would you like to join the COVID-19 Wellness Monitoring Programme?
-- Select --
Yes
No
Which Shul do you belong to?
Have you attended Shul, School, or a Charity Organization in the last 7 days?
-- Select --
Yes
No
Please specify which one?
Have you been tested for COVID-19?
-- Select --
Yes
No
Are you Covid Positive?
-- Select --
Yes
No
Awaiting Results
COVID Confirmed Date (Date cannot be older than 2 months)
Day Start of Symptoms (Date cannot be older than 2 months)
When was your test done? (Date cannot be older than 2 months)
Why are you Signing Up?
Basic Info
Name
Surname
Email
Gender
-- Select --
Male
Female
Other
Age
Contact Number
Notes and Other Information
We would like to add all hospitalised patients to a Tehillim whatsapp/telegram group, if you consent to being added please provide your Hebrew name and your mother's Hebrew name in the fields provided
I would like to be added to a Tehillim group.
Hebrew Name
Mother's Hebrew Name
Contact Details
Unit Number
Complex/Building Name
Search Address
Address
Suburb
GP Name
GP Contact Number
Next of Kin Name
Next of Kin Surname
Next of Kin Contact Number
Next of Kin Relationship
Vaccinations
Have you been Vaccinated?
-- Please Select an Option --
Yes
No
When were you Vaccinated?
Which vaccine did you receive?
-- Please Select an Option --
Johnson and Johnson
Pfizer
Moderna
Sputnik
AsterZeneca
Sputnik V
Number of shots taken?
-- Please Select an Option --
1
2
When did you recieve your first shot?
When did you recieve your second shot?
Medical Conditions
Do you have Hypertension?
-- Select --
Yes
No
Do you have COPD?
-- Select --
Yes
No
Do you have Asthma?
-- Select --
Yes
No
Are you HIV Positive?
-- Select --
Yes
No
Do you have an Auto Immune Disease?
-- Select --
Yes
No
Do you take Chronic Steroids?
-- Select --
Yes
No
Do you have Diabetes?
-- Select --
Yes
No
Are you Obese?
-- Select --
Yes
No
Do you have any Cardiovascular Disease?
-- Select --
Yes
No
Do you have Renal Disease?
-- Select --
Yes
No
Do you have Inflammatory Bowel Disease?
-- Select --
Yes
No
Do you have Dementia?
-- Select --
Yes
No
Do you have Cancer?
-- Select --
Yes
No
If Female, are you Pregnant?
-- Select --
Yes
No
Do you have any Solid Organ Transplants?
-- Select --
Yes
No
By completing this form, I am giving permission to CSO Cape Town to contact me on a regular basis during my isolation period.I agree to co-operate with the assigned volunteer and will provide said volunteer with any medical information that they require.
I acknowledge and agree that CSO Cape Town reserves the right to remove me from the programme should I be found not to be adhering to the regulations and / guidelines as prescribed, from time to time, by the National Institute of Communicable Diseases(NICD) or otherwise for good reason, as determined in CSO Cape Town’s reasonable discretion.
I hereby consent to home visit from the CSO Cape Town nursing sister when needed, for monitoring and assessment purposes while on the Wellness Programme. Should my GP request blood samples to be drawn, I consent for this to be done by the nursing sister and samples to be taken to the laboratory for testing.
Register
