Medical History:

* Name:

Who is on your Health team? Therapists, doctors, homeopaths, etc?

Are you skeptical about Alternative Medicine and practices?

Do you experience allergic reactions to any foods, drugs, or environmental substances?

Are you currently taking any medications or supplements?
If yes, please explain for what reason….

Do you have any physical challenges or medical conditions that would make exercise or bodywork difficult or impossible?

Please list any injuries or surgeries that you may have had in the past.

Do you have high/low blood pressure, circulatory problems, diabetes, or ANY  other medical disease that you are challenged with?

Do you smoke or drink alcohol? If yes, how much?

Do you have special dietary needs we should be informed of?

During the retreat, would you be able to follow a simple vegan diet and fast ocasionally? If not, what is the reason?

Would you consider yourself mentally balanced and stable? Have you ever had psychological or psychiatric treatment?

Would you consider yourself emotionally balanced and strong?

Anything else you would like to add?

Thank you for taking your time to answer the questions.
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