Health Check Form Questionnaire

Confidential Information

The following confidential information will be treated with strict confidence. The information is required for your safety and to benefit your health. There may be certain contraindications, which will require special attention and/or further discussion. It may be necessary to consult with your Medical Practitioners before the start of any of our retreat or online programs. Take your time to fill out this health Questionnaire with complete honesty, a thorough health screening can help us to personally tailor together the most efficient retreat or online wellness program. 

Health History

Please be as detailed as possible


Intake of Stimulants or Depressants, Opiates (Drug derived from opium, psychoactive compounds such as morphine, codeins, thebaine), Hallucinogenic (Psychedelics, dissociatives, deliriants), Benzodiazepine These are sedatives, hypnotics (sleep inducing), anxiolitic (anti-anxiety) anticonvulsants and muscle relaxants. (Psychoactive drugs such as chlorodiazepxide (Librium) or Diazepam (Valium)), Cannaboids Most notable is tetrahydrocannabinol (THC), Solvents (Distinct chemical liquid, solid or gas), Amphetamins (Stimulants, empathogens, hallucinogens), Alcohol , Nicotine. Others

Important Health Questions

Do you have or have you had any of the following?


THYROID/PARATHYROID (GLANDULAR SYSTEM)


PANCREAS


ADRENAL GLANDS (GLANDULAR SYSTEM)


FEMALES ONLY


MALES ONLY


GASTRO INTESTINAL TRACT


LIVER / GALLBLADDER / BLOOD


HEART AND CIRCULATION


SKIN


LYMPHATIC SYSTEM


KIDNEY AND BLADDER


LUNGS


Are you a smoker? How often? How many packs or cigarettes a day?

ENVIRONMENTAL TOXINS