.:: CFFSD : Online Forms ::.

Name:

Family:

Name of the father:

e-Mail:

Username:

Password:

Confirm password:

Telephone number:

Residing address:

Ever used the educational or cultural materials of the CFFSD?

yes

no

To what extent these subjects have been useful to you?

Very little

little

fairly

much

very much

If you are a patient, what is the type of your disease?

What kind of treatment you have received?

What is the name of the treatment center you refer to?

How many years you have been ill?

year(s)

Are the medicines you are using?

Do you have medical insurance?

yes

no

How satisfied you are with your medical insurance?

not much at all

very little

fairly satisfaction

very much

a lot