Healthcare Questionnaire

1) Biographic Information

NYARKO
Family Name (Last Name): ______________________________________________
Given Name (First Name): _____________________________________________
FAUSTINA
Middle Name: _________________________________________________
House Number and Area/Street Name: J 17/17
___________________________________
Apt. Suite Floor: ________________________
City or Town: _____________
JUABOSO WESTERN NORTH
Province/State: ___________
GHANA
Country of Residence ________________ Zip Code: ____________
WQ-0006-9880
0557024202
Home/Mobile Number: ________________ fn81119@gmail.com
Email Address: _____________________
Social Security Number (if applicable): _____________________
Date of Birth (mm/dd/year): ________________
07/30/1996 ODUBI
City or Town of Birth: _______________
State/Province of Birth: _____________________
ASHANTI REGION
Country of Birth: _________________________
GHANA Country of Citizenship: __________________
GHANA

2) Marital Status
What is your current marital status? ________________________________
MARRIED
Spouse’s Family Name (Last Name): _____________________________________
ESSEL
JOHN
Spouse’s Given Name (First Name): _____________________________________
Middle Name: _____________________________
Social Security Number (if applicable): _________________
Date of Birth (mm/dd/year): _________________
05/11/1990 AGONA SWEDRU
City or Town of Birth: ___________________
CENTRAL REGION
State/Province of Birth: ________________________
Country of Birth: _______________________
GHANA Country of Citizenship: ____________________
GHANA

3) Children – Please attach additional children information on a separate sheet of paper

I) Child’s Family Name (Last Name): _____________________________________
ESSEL
Child’s Given Name (First Name): _____________________________________
JOSHUA

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 NII-ARMAH
Middle Name: _____________________________
Social Security Number (if applicable): _________________
Date of Birth (mm/dd/year): _________________
04/13/2016 City or Town of Birth: ___________________
ACCRA-TESHIE
State/Province of Birth: ________________________
GREATER ACCRA REGION
Country of Birth: _______________________
GHANA Country of Citizenship: ____________________
GHANA

I) Child’s Family Name (Last Name): _____________________________________ Child’s

Given Name (First Name): _____________________________________
Middle Name: _____________________________
Social Security Number (if applicable): _________________
Date of Birth (mm/dd/year): _________________ City or Town of Birth: ___________________
State/Province of Birth: ________________________
Country of Birth: _______________________ Country of Citizenship: ____________________

II) Child’s Family Name (Last Name): _____________________________________

Child’s Given Name (First Name): _____________________________________
Middle Name: _____________________________
Social Security Number (if applicable): _________________
Date of Birth (mm/dd/year): _________________ City or Town of Birth: ___________________
State/Province of Birth: ________________________
Country of Birth: _______________________ Country of Citizenship: ____________________

III) Child’s Family Name (Last Name): _____________________________________ Child’s

Given Name (First Name): _____________________________________
Middle Name: _____________________________
Social Security Number (if applicable): _________________
Date of Birth (mm/dd/year): _________________ City or Town of Birth: ___________________
State/Province of Birth: ________________________
Country of Birth: _______________________ Country of Citizenship: ____________________

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4) Education – Provide your college education history, whether inside or outside the United
Kingdom. If additional spaces are needed, please attach the additional education history on a
separate sheet of paper.

First Degree
Name of University: __________________________________________________________
Street Name and Number: _____________________________________________________
City or Town: ________________________ State/Province:_______________________
Zip Code: __________________
Country: ____________________________________
Start date (mm/year): ___________________ Graduation (mm/year): __________________
Degree Received: _____________________________

Second Degree
Name of University: __________________________________________________________
Street Name and Number: _____________________________________________________
City or Town: ________________________ State/Province:_______________________ Zip
Code: __________________
Country: ____________________________________
Start date (mm/year): ___________________ Graduation (mm/year): __________________
Degree Received: _____________________________

5) Employment History – Provide your employment history, whether inside or outside the
United Kingdom. Provide the current employer first. You must list the employer you worked for,
not the client’s name of the project you were assigned to. If additional spaces are needed,
please attached the additional employment history on a separate sheet of paper

Employer 1 (Current Employer)

Name of Employer: __________________________________________________________
JUABOSO DISTRICT GOVERNMENT HOSPITAL

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 JUABOSO GOVERNMENT HOSPITAL
Street Number and Name: _____________________________________________________
Apt. Suite Floor: ________________________
City or Town: _________________________
JUABOSO State/Province: _______________________
WESTERN NORTH REGION
Zip Code: ________________________
WQ-0006-9880 Country: ___________________________
GHANA
Type of Business: ____________________________________________________________
PUBLIC HOSPITAL
Occupation: _____________________
NURSING Current Salary: _____________________
2,600.00
Supervisor’s Name: ____________________
OSEI ASIBEY EBENEZER
0547438057
Supervisor’s Phone Number: _____________________
04/15/2021-DATE
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________
Job Description: ________________________________________________________________
PREOPERATIVE OPERATION OF CLIENTS BOOKED FOR SURGICAL CASES
______________________________________________________________________________
AND ASSISTING SURGENTS IN SURGICAL PROCEDURES LIKE; CEASARIAN SECTION.
Technical Skills Used: ____________________________________________________________
MONITORING SURGICAL PATIENTS POST OPERATIVELY BY PUTTING
THEM ON CARDIAC MONITOR
______________________________________________________________________________

Employer 2
Name of Employer: __________________________________________________________
OYOKO CLINIC
Street Number and Name: _____________________________________________________
ADENTA STREET
Apt. Suite Floor: ________________________
City or Town: _________________________
MADINA-ADENTA GREATER ACCRA
State/Province: _______________________
+233
Zip Code: ________________________ GHANA
Country: ___________________________
Type of Business: ____________________________________________________________
PRIVATE HOSPITAL
NURSING
Occupation: _____________________ Current Salary: _____________________
1,000.00
OSCAR AWIAH
Supervisor’s Name: ____________________
Supervisor’s Phone Number: _____________________
0206732765
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________
08/05/2020 - 02/18/2021
Job Description: ________________________________________________________________
MONITORING OF VITAL SIGNS TO MANAGE EMERGENCIES PROMTLY
______________________________________________________________________________
AND PERFORM NURSING CARE PLAN IN RESPONSE TO CLIENTS NEEDS.
ACTIVELY INVOLVE IN MANAGING ASTHMATIC PATIENT BY
Technical Skills Used: ____________________________________________________________
______________________________________________________________________________
PLACING THEM ON NEBELIZER AND OXYGEN THERAPY.

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Employer 3
37 MILLITARY HOSPITAL
Name of Employer: __________________________________________________________
Street Number and Name: _____________________________________________________
NEGEHALLI BARRACKS LIBERATION Rd 37
Apt. Suite Floor: ________________________
City or Town: _________________________
ACCRA State/Province: _______________________
GREATER ACCRA
+233
Zip Code: ________________________ Country: ___________________________
GHANA
PUBLIC HOSPITAL
Type of Business: ____________________________________________________________
NURSING
Occupation: _____________________ 800.00
Current Salary: _____________________
Supervisor’s Name: COLNEL
____________________
SIMPONG
Supervisor’s Phone Number: _____________________
0243844910
04/12/2019 - 03/10/2020
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________
WOND DRESSING FOR ACCIDENT VICTIMS AND MONITORED PATIENTS
Job Description: ________________________________________________________________
______________________________________________________________________________
WITH KIDNEY FAILURE BOOKED FOR DIALYSIS SESSION.
Technical Skills Used: ____________________________________________________________
PASSED NASOGASTRIC TUBE FOR PATIENT WITH GASTRIC IMMOBILITY
AND BOWEL OBSTRACTION.
______________________________________________________________________________

Employer 4
Name of Employer: __________________________________________________________
ANKAFUL PSYCHIATRIC HOSPITAL
ANKAFUL ROAD, CAPE COAST
Street Number and Name: _____________________________________________________
Apt. Suite Floor: ________________________
City or Town: _________________________
CAPE COAST State/Province: CENTRAL
_______________________
REGION
Zip Code: ________________________
+233 Country: ___________________________
GHANA
Type of Business: ____________________________________________________________
PUBLIC HOSPITAL
Occupation: _____________________
NURSING Current Salary: _____________________
400.00
MR. APIKENU ALBERT ACHU
Supervisor’s Name: ____________________
Supervisor’s Phone Number: _____________________
02463429990
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________
03/03/2012 - 07/21/2013
Job Description: ________________________________________________________________
REHABILITATION MANAGEMENT NURSE
______________________________________________________________________________

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 ENGAGING THE MENTALLY ILL TO ENHANCE RECOVERY
Technical Skills Used: ____________________________________________________________
______________________________________________________________________________
Employer 5
DUNKWAW GOVERNMENT HOSPITAL
Name of Employer: __________________________________________________________
X638+J3w,
Street Number and Name: _____________________________________________________
Apt. Suite Floor: ________________________
City or Town: _________________________
DUNKWAW-ON-OFFIN State/Province: _______________________
CENTRAL REGION
+233
Zip Code: ________________________ Country: ___________________________
GHANA
Type of Business: ____________________________________________________________
PUBLIC HOSPITAL
Occupation: _____________________
NURSING Current Salary : _____________________
200.00
Supervisor’s Name: MR.
____________________
SOLOMON YAGNUU
Supervisor’s Phone Number: _____________________
0243844910
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________
01/11/2015 - 06/20/2015
Job Description: ________________________________________________________________
VOLUNTEER NURSE
______________________________________________________________________________
Technical Skills Used: ____________________________________________________________
WENT FOR OUTREACH PROGRAMS TO LESS PRIVILAGE
COMMUNITIES AND PROVISION OF EDUCATION ON HIV PREVENTION.
______________________________________________________________________________

Employer 6
Name of Employer: __________________________________________________________
Street Number and Name: _____________________________________________________
Apt. Suite Floor: ________________________
City or Town: _________________________ State/Province: _______________________
Zip Code: ________________________ Country: ___________________________
Type of Business: ____________________________________________________________
Occupation: _____________________ Current Salary: _____________________
Supervisor’s Name: ____________________
Supervisor’s Phone Number: _____________________
Dates of Employment: From (mm/dd/year) To (mm/dd/year): __________________________

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Job Description: ________________________________________________________________
______________________________________________________________________________
Technical Skills Used: ____________________________________________________________
______________________________________________________________________________

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 Healthcare
Questionnaire
DIPLOMA EDUCATION
Name of Nursing Training College: Dunkwaw On-Offin Nursing and Midwifery
Traning College

Street Name and Number: X68F+433

City or Town: Dunkwaw on-Offin State/Province: Central Region
Zip Code: WQ-0006-9880
Country: GHANA
Start date (mm/year): 08/2015 Graduation (mm/year): 09/2018
Diploma Received: REGISTERED GENERAL NURSING

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