What is your Appointment Date? *

Applicable to individuals ONLY getting a consultation NOT Live-In Wellness Participants

MM

DD

YYYY

What is your Appointment Time? *

Applicable to individuals ONLY getting a consultation NOT Live-In Wellness Participants

Hour

Minute

Second

AM PM

Name *

First Name

Last Name

Street *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

Country

(###)

###

####

Alternate Phone

Country

(###)

###

####

Gender *

Male

Female

Emergency Contact *

Emergency Contact must be someone NOT at the retreat with you.

First Name

Last Name

Emergency Phone *

Country

(###)

###

####

When did you last consult a physician? *

MM

DD

YYYY

What specific conditions would you like to address? *

Addictions

Arthritis

Cancer

Diabetes

Heart Disease

High Blood Pressure

Hormonal Imbalance

Overweight

Underweight

Stress

Other

Rate your stress level

(1 very little stress and 10 an extreme amount of stress)

1

2

3

4

5

6

7

8

9

10

Are you developing your mental and spiritual life by daily study, meditation and prayer?

Yes

No

Are you involved in some type of activity in which you are helping others?

Yes

No

Do you sleep with windows closed? *

Yes

No

Are you able to breathe fresh air while you are working? *

Yes

No

Is the building where you work a non-smoking facility? *

Yes

No

Do you often get sunburned? *

Yes

No

Do you visit tanning beds? *

Yes

No

Are you afraid of getting skin cancer? *

Yes

No

What time do you go to bed? *

Hour

Minute

Second

AM PM

What time do you awaken? *

Hour

Minute

Second

AM PM

What time is your last meal before retiring? *

Hour

Minute

Second

AM PM

Do you snack just before bedtime?

Yes

No

Do you wake up during the night and snack? *

Yes

No

Do you have trouble sleeping? *

Yes

No

What type? *

Spring

Filtered

Distilled

Tap

Do you ingest caffeine in any form? *

Yes

No

Do you smoke or chew tobacco? *

Yes

No

Do you drink alcohol? *

Yes

No

Have you drunk alcohol in the past? *

Yes

No

Do you have a peaceful environment at meal times? *

Yes

No

Do you have a set meal time? *

Yes

No

Are you following any special diet? *

Yes

No

Do you over eat? *

Yes

No

Do you feel stuffed after your meals? *

Yes

No

Do you eat between meals? *

Yes

No

Do you drink with your meals? *

Yes

No

Do you eat animal products? *

Yes

No

Do you eat dairy products? *

Yes

No

Do you eat desserts, candy or other sweets regularly? *

Yes

No

What time do you eat breakfast? *

Hour

Minute

Second

AM PM

What time do you eat lunch? *

Hour

Minute

Second

AM PM

What time do you eat supper? *

Hour

Minute

Second

AM PM

HEAD

Headaches

Blurred vision not corrected by glasses

Pain in your eyes

Double vision

Light flashes

Ear pain

Drainage from Ears

Hearing difficulties or deafness

Buzzing of ringing in ears

Mouth or tongue problem

Persistence hoarseness

Difficulty swallowing

Mouth fillings

Root canals

Other

SKIN

Changing mole

Rashes

Yellow skin

Other Skin problems

NECK

Swelling

Lumps

Stiffness

Other

CHEST, HEART AND LUNGS

Shortness of breath

Chest pain or pressure attack

Poor exercise tolerance

Frequent cough

Coughing up blood

Unusual heart beat

Wheezing

Swollen ankle

Other

GASTROINTESTINAL

Poor appetite

Nausea or vomiting

Indigestion or heart burn

Vomiting blood

Abdominal cramps

Abdominal pain or swelling

Irregular bowel movements

Other

KIDNEY

Blood in urine

Difficulty passing urine

Difficulty controlling urine

Getting up at night to urinate

Pain or burning while urinating

Other

GENITALIA (WOMEN)

Breast Lump

Discharge from nipple

Hot flashes

Pain not associated with period

Pain with intercourse

Changes in period

PMS

Regularity

Flow

Vaginal bleeding

Other

GENITALIA (MEN)

Breast lump

Discharge from penis

Sore on penis

Lump in testicles

Difficulty having erection

Other

NEUROMUSCULAR

Weakness in arm and leg

Dizzy spells

Fainting spells

Speech difficulty

Difficulty balancing

Other

BONE/JOINT

Painful joint

Swollen joints

Loss of muscle strength

Lump or swelling in muscle

Lump on bones

Back Pain

Other

ENDOCRINE

Thirsty all of the time

Cold most of the time

Too warm most of the time

Unusually tired or sluggish

Unusually jumpy or nervous

Do you find your life *

Generally unsatisfactory

Too demanding

Boring

Satisfactory

Fantastic

Do you worry about

Money

Job

Home life

Children

Do you

Cry easily

Feel inferior to others

Feel shy

Feel things always goes wrong

Often feel depressed

Have irrational fears

Feel anxious or upset

Have you seriously considered suicide in the last 12 months *

Yes

No

Date *

MM

DD

YYYY