Name *

First & Last Name

First Name

Last Name

Phone Number *

Country

(###)

###

####

Medications *

Are you currently, or have you in the last 90 days taken any pharmaceutical medications?

YES

NO

Have you ever been diagnosed with a life threatening illness? *

YES

NO

Do you have a history of drug addiction? *

Yes

No

Do you have a history of heart conditions? *

YES

NO

Do you have a history of high or low blood pressure? *

YES

NO

Do you have a history of fainting in the last 5 years? *

YES

NO

Have you ever had what you might call a Major Life Trauma? *

near death experience, tragic death of a loved one, life threatening illness, serious addiction, physical, emotional sexual abuse, military service in wartime, incarceration, childhood abandonment, etc...

YES

NO

Do you find yourself having suicidal thoughts? *

Yes

No

Often

Occasionally

In the past, but not in many years.

Have you ever attempted suicide before? *

Yes

No

Have you ever been diagnosed with a Mental Imbalance or Disorder, or do you feel you may have an undiagnosed mental disorder? *

bi-polar disorder, schizophrenia, manic depression, post-traumatic stress disorder, etc...

YES

NO

Have you ever been diagnosed with type 1, type 2, or pre-diabetes? *

YES

NO

Do you feel you may have any major undiagnosed health conditions, that you think we should be aware of? *

YES

NO

Do you have a history of liver, kidney or gall bladder problems? *

YES

NO

Have you ever suffered severe head trauma, concussion, etc? *

Yes

No

Have you ever undergone surgery to remove any of your organs, limbs, etc?? *

Yes

No

If you were asked to avoid all drugs, alcohol and pork for 2 weeks before attending ceremony, would you be willing to commit yourself to abstaining? *

Yes

No

I will do my best

I agree that all the information I have shared in this form is accurate & thorough, and I agree to not withhold any medical history related information that could be useful to assuring my safe participation in this retreat. *

Yes, I agree