Name Address Email *
Phone
Date of Birth
Age
Height
Weight
Occupation
Work History
Primary Health Complaints
Your personal health goals you would like to achieve
Brief History of Health Complaints
History of Medications (Include Past and Current)
History of Vitamins, Supplements, Herbs, etc. (Include Past and Current)
History of Surgeries and Hospitalizations
History of Drugs, Caffeine, and Alcohol (Include Past and Current)
Current Sleeping Patterns
History of Exercise Patterns
History of Diet (Include Past and Current)
Frequency of Bowel Movements / Day / Week
Have you ever done an enema? If yes, please explain.
Have you ever done any fasting or water fasting before? If yes, what type of fasting and how many days?
Have you ever done any detox or cleansing protocols? If yes, please specify which detox protocols.
Were you conceived via a natural birth, cesarean section, other, or uncertain?
Are your mother and father living? Please describe your relationships with your parents (Include Past and Current).
How is the health of your parents (alive currently or their health prior to their passing)?
Are you currently married, single, or in a committed relationship?
Do you have children? If yes, what are their ages? Are you still in a relationship with the other parent?
Have you experienced any Amazonian and / or African plant medicines? If yes, which medicines have you experienced?
Are you prepared to make diet and lifestyle changes to improve your health?
Are you open to receiving new education?
How did you learn about our professional retreat services?
Additional Information you would like for us to know.
