Chronic Illness Institute - life,health,family,workshops,patient,healthcare,professionals,condition,care,chronic,disease,organization

Please complete the form below as accurately as possible to ensure our efficient reponse to your enquiry.

Is your enquiry for a:

Business

Other Organization

Individual

* First Name:
* Surname:
Company / Organisation (if applicable):
Country:
* City / Town:
* E-mail:
* Confirmation of E-mail:
* Cell / Mobile Number:
* Tel Work:
* Tel Home:
How did you hear about us

Your main interest is:
Please note that you can tick more than one

BBBEE enhancing score card points
Events / Workshops
Training
CII Foundation (Section 21)
CRM
Entrepreneurs Package

Caregiver
Family
Youth life skills development
School program
Program's for the literacy challanged
Company High Absenteeism

If you are an Individual please tick the symptoms that you experience at present:
Please note that you can tick more than one

Fatigue	Stress
Headaches	Migraine
Breathing difficulties	Sweats
Memory loss	Concentration difficulties
Depression	Mood Swings
Sleep Disturbances	Muscle Pain
Skin sensitive to touch	Joint Pain
Skin rashes	Tremor
Pins and needles or numbness in fingers and/or toes	Numbness of the face
Sore throat	Swollen Glands
Post Nasal Drip/Sinus	Furry Tongue Feeling
Sensitivity to light	Ear – sensitivity or ringing (tinnitus)
Poor body temperature control	Dizziness – Loss of balance
Visual disturbances	Paralysis
Chest pain/palpitations	Abdominal/bowel disorder
Nausea – occasional or continual	Poor bladder control
Bruising – easily or not	Skin problems
Paralysis	Allergies
Cold feet and hands
Other:

Please click here to read CII Disclaimer
Please tick that you have read and accept our disclaimer

This information is intended only for residents of South Africa.
Disclaimer © Copyright Chronic Illness Institute. All Rights Reserved.
Website designed and hosted by LIT Creations You are Visitor Number: 2802