Contact & Registration

✉️ Contact us ⭐ Feedback 🍲 Register for an event 🏞️ Health Retreat 💻 Tele Health assessment 🩺 On-site consultation 🥗 Nutrition assessment

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Contact us

Questions about consultations, programs, services or anything else. We will get back to you.

Your name *

Phone / WhatsApp number *

Email (optional)

What is it about?

Your message *

Feedback

Tell us what went well and what we can do better. Your name is optional.

Your name (optional)

Phone or email (optional, if you would like a reply)

What is your feedback about?

How was your experience?

Excellent Good Okay Poor Very poor

Your feedback *

Register for an event

Cooking school, health seminar, health exposition and more. We will confirm the details with you.

Which event? *

Event name, place or date (if you know it)

Full name *

Phone / WhatsApp number *

Email (optional)

How many people are coming? *

Town or city

Anything we should know? (dietary needs, access needs)

Register for a Health Retreat

Tell us about yourself and your health so we can plan your retreat safely. It takes about 5 minutes.

Your details

Full name *

Age *

Sex *

Female Male

Phone / WhatsApp number *

Email (optional)

Where do you live? (town, country) *

Your retreat

Preferred dates or month *

How many people are coming? *

What would you like the retreat to help you with? *

Emergency contact

Name and relationship *

Their phone number *

I confirm this information is correct as far as I know, and I agree that Eden Maranatha may use it to plan my care. *

Tele Health Online Assessment

Register for an online assessment with Dr Hleza by completing our medical history form. Please take your time and answer as fully as you can. If the patient is under 18, a parent or guardian should fill it in.

🔒 This information is treated as strictly confidential.

Your details

Title

Surname *

First names *

ID or passport number

Date of birth *

Age *

Sex *

Female Male

Cell phone / WhatsApp *

Other phone number

Home address

Postal address

Next of kin (full name and phone) *

Your medical doctor

Doctor's name

Town

How did you hear about us?

Survey Doctor Friend Family member Advertisement Church Other

If other, please specify

Parent or guardian (only if the patient is under 18)

Parent or guardian's full name

Address

Contact number

Personal history

Birth place

Nationality

Religion

Occupation

Education level completed

Marital status

Single Married Divorced Separated Widowed Life partner

Hours of sleep per night

Time you get up

Bed time

Hours a day watching TV

Exercise (type and how often)

Free time activities

Current or previous diagnoses

Medicines you take (including vitamins, minerals, supplements, hormones, over-the-counter drugs and street drugs): name, dosage and how long you have used it

Family history

Has anyone in your immediate family had any of these? (tick all that apply)

Anemia Bleeding tendency Leukemia Repeated infections Arthritis Heart disease Lung disease TB High blood pressure Kidney disease Asthma Severe allergies Mental illness Convulsions Migraine headaches Diabetes Gout Obesity Thyroid trouble Peptic ulcer Chronic diarrhea Cancer Stroke

Present age and health (good, fair or poor) of your father, mother, brothers and sisters, and children

How often you pass stools

Colour of urine

For females only

Menopausal symptoms

Yes No

Post-menopausal bleeding

Yes No

Date of last Pap smear

Number of pregnancies

Number of births

Number of miscarriages

Age periods started

Days between periods

Period length (days)

Date of last period

Age at menopause

Flow

Light Normal Heavy

Breasts: for each, choose Past, Recent (within the last 12 months) or Current problem.

Breast pain

Breast lumps

Nipple discharge

Allergies and operations

For each allergy, choose Past, Recent (within the last 12 months) or Current.

Tetanus antitoxin

Penicillin

Sulpha

Cosmetics

Other allergies

Operations (please specify)

For males only

Do you have any of these challenges? (tick all that apply)

Erectile dysfunction (ED) Pain during intercourse Low libido (reduced sex drive) STIs (sexually transmitted infections) Premature ejaculation Fertility challenges Big belly and weight Discharge Delayed start of urination Prolonged urination Hot sensation when urinating Dripping after visiting the toilet Difficulty holding urine

Current diet

What does a typical meal look like for you?

Breakfast

Lunch

Supper

Your Tele Health assessment

Main reason for the assessment *

Preferred way to meet online

WhatsApp video call Zoom Google Meet No preference

Best days and times for you

I confirm that the information I have given is true and complete as far as I know. *

Signature: type your full name *

One-on-One On-Site Consultation

Coming to see Dr Hleza in person? Fill in your medical history before your visit so your consultation time is spent on you. Consultancy: 56 Kingsmead, Harare, Monday to Friday.

Your details

First name *

Surname *

Date of birth *

Age *

ID number

Sex *

Female Male

Cell / WhatsApp *

Work phone

Home phone

Address

Next of kin

Full name *

Address

Phone number *

Your visit

Preferred date

Preferred time

Medical history

Medications (name, dosage and how long you have been taking it)

Colour of urine

How often you pass stools

Known allergies or intolerances

Operations or medical procedures done

Family history: relatives with a known chronic disease

Current diagnosis

For females only

Last Pap smear

Last breast examination (self or clinic)

Menopause

Menstrual cycle

Heavy Normal Light

For males only

Tick any that apply

ED (erectile dysfunction) Low libido Premature ejaculation STIs Pain during intercourse Prolonged urination

What do you usually eat?

Breakfast

Lunch

Supper

Consent

I hereby give my permission to Dr C F Hleza to administer treatment and to perform such procedures as deemed necessary in the diagnosis and/or treatment of the current condition. I understand that I am financially responsible for the cost and any balance on my account. All information I have provided is true. *

Signature: type your full name *

Nutrition & Diet Assessment

For Nutrition Therapy. A short questionnaire about what you have usually eaten and drunk over the last 4 weeks. There are no right or wrong answers, and a guess is better than leaving a blank. It is fine to count the same food more than once: a smoothie can count as fruit and as nuts.

Your details

Full name *

Phone / WhatsApp *

Age

Over the last four weeks, how often did you eat or drink these?

Anything else about how you eat? (optional)

Contact us

Feedback

Register for an event

Register for a Health Retreat

Your details

Your retreat

Emergency contact

Tele Health Online Assessment

Your details

Your medical doctor

Parent or guardian (only if the patient is under 18)

Personal history

Family history

For females only

Allergies and operations

For males only

Current diet

Your Tele Health assessment

One-on-One On-Site Consultation

Your details

Next of kin

Your visit

Medical history

For females only

For males only

What do you usually eat?

Consent

Nutrition & Diet Assessment

Your details

Over the last four weeks, how often did you eat or drink these?

Medical history

Lifestyle

Where to find us

Contact & registration

✉️ Contact us

⭐ Feedback

🍲 Register for an event

🏞️ Register for a Health Retreat

Your details

Your retreat

Emergency contact

💻 Tele Health Online Assessment

Your details

Your medical doctor

Parent or guardian (only if the patient is under 18)

Personal history

Family history

For females only

Allergies and operations

For males only

Current diet

Your Tele Health assessment

🩺 One-on-One On-Site Consultation

Your details

Next of kin

Your visit

Medical history

For females only

For males only

What do you usually eat?

Consent

🥗 Nutrition & Diet Assessment

Your details

Over the last four weeks, how often did you eat or drink these?

Medical history

Lifestyle

Where to find us

Contact us

Feedback

Register for an event

Register for a Health Retreat

Tele Health Online Assessment

One-on-One On-Site Consultation

Nutrition & Diet Assessment