G E N E R A L I N F O
Name: _________________________________________Date: ____________________
Male ⊂⊃ Female ⊂⊃ Course Attending: _______________________________________
Age: ________ Date of birth: ______________
Occupation: _____________________________________________________________________
Marital Status: ______________________ Children: ____________________________________
In case of emergency, please contact:
Name / Relationship to you: ________________________________________________________
Phone # (home): ________________________ (work): __________________________________
Address: ________________________________________________________________________
Back-up emergency contact: ________________________________________________________
Phone # (home): ________________________ (work): __________________________________
Address: ________________________________________________________________________
M E D I C A L H I S T O R Y
Are you under the care of a medical professional for a current condition? If yes, please explain. ________________________________________________________________________________
________________________________________________________________________________
If yes, have you discussed your participation in this program with him/her? ___________________
(We are available to discuss with your doctor any medical needs you might have).
Are you currently taking any medications? If so, please list medication and
condition. ________________________________________________________________________
_________________________________________________________________________________
If yes, what are the food requirements for your medication? ________________________________
_________________________________________________________________________________
Do you smoke? __________
Have you had any major surgery? If so, please list the reason and the date. ____________________
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Please list all significant accidents and injuries and the approximate dates. _____________________
_________________________________________________________________________________
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Have you been hospitalized recently (past 2 years)? If so, please explain. ______________________
_________________________________________________________________________________
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List any allergies to medication: _______________________________________________________
__________________________________________________________________________________
Do you have any SERIOUS food allergies that cause medical complications? If yes,
please list them, and rate the severity on a scale of 1-10. ____________________________________
__________________________________________________________________________________
**(Please note that we are not always able to accommodate mild food allergies/sensitivities.
We are concerned with foods that you can NOT, under any circumstances, eat without serious side effects)
Do you carry an EPI-PEN for your food (or other) allergy? ___________
Other serious allergies: _______________________________________________________________
List any areas of weakness in your body _________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
On a scale of 1-10, how would you rate your current physical condition? _____________
√ Check if you have had any history of the following
(and circle any that are current) |
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⊂⊃ Heart disease
⊂⊃ High blood pressure
⊂⊃ Low blood pressure
⊂⊃ Diabetes
⊂⊃ Hyper/Hypoglycemia
⊂⊃ Asthma
⊂⊃ Arthritis
⊂⊃ Poor circulation
⊂⊃ Anemia
⊂⊃ Dizziness or loss of balance
⊂⊃ Back or neck problems
⊂⊃ Headaches |
Is there any medical condition not listed here that could impact your participation in this
program that we should know about? Please describe. ______________________________________
__________________________________________________________________________________
__________________________________________________________________________________
In the event of a medical emergency, do you have medical insurance? _________________________
Please list insurance information (insurance company, contact information, policy #,
name of insured and relationship to you, etc) _____________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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P S Y C H O L O G I C A L P R O F I L E
Are you currently under the care of a mental health professional? If yes, please
explain. ___________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
If yes, have you discussed your participation in this program with him/her? _____________________
Have you ever experienced or been treated for depression? Please explain. ______________________
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Are you currently experiencing depression? If so, how severe? _______________________________
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History of addictions: ________________________________________________________________
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Do you now or have you ever suffered from any kind of anxiety disorder (i.e. panic
attacks, night terrors, phobias, flashbacks, etc.)? If yes, please explain. ________________________
__________________________________________________________________________________
__________________________________________________________________________________
Do you now or have you ever suffered from any type of dissociate disorder, or bipolar
disorder (some types of energy work are contraindicated for these conditions)? If yes,
please explain: ______________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Have you undergone any stressful events in the past two years that have impacted you
significantly (i.e. loss of a loved one, divorce, loss of employment, etc.)? Please explain.
__________________________________________________________________________________
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__________________________________________________________________________________
__________________________________________________________________________________
Have you ever been the victim of violence, physical or sexual? If yes, at what age?
__________________________________________________________________________________
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O T H E R P R A C T I C E S / L I F E S T Y L E
These questions are designed to get an idea of who our students are and what unique backgrounds you bring. We celebrate the diversity of the people who come to us. Some of you may have no experience in any of these areas, and that's perfectly fine. No prior experience is required unless specifically stated in the course description. For the retreats we offer that deal specifically with some of these skills, this will give us an idea. |
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Do you have a current exercise routine/ physical practice? How often? How strenuous?
__________________________________________________________________________________
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How would you describe your current dietary habits
(how much caffeine, sugar, meat, junk food, fruits and vegetables, etc. -- be honest!)
________________________________________________________________________
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________________________________________________________________________
________________________________________________________________________
Do you have any hobbies? _____________________________________________________
________________________________________________________________________
Do you meditate? _____________________
If yes, what type, since when, how frequently, and how long is each session? _________________
________________________________________________________________________
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Have you ever done yoga? _____________
If yes, what type, and what is your level of experience? ________________________________
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Have you ever fasted? If so, what type of fast and for how long? __________________________
________________________________________________________________________
Have you ever done any type of pranayama / breathwork? What type? ______________________
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Have you studied any type of internal energy work (i.e. chi gung, tai chi, healing, etc.)?
If so, what type and for how long? _______________________________________________
________________________________________________________________________
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Have you ever done a Vision Quest? How many? _____________________________________
________________________________________________________________________
Please list any other intensives, retreats, or Sacred Ceremony that you've been a part of:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Are you and adherent of any spiritual or religious system? If so, which one? __________________
________________________________________________________________________
Are you happy with the direction of your life? Why or why not? __________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How much control do you feel you've had over the direction your life is going? Please
explain. __________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you ever taken classes or other programs with The Total Human™
or The Earth-Heart Institute of Vision and Healing?
If so, which ones? ___________________________________________________________
________________________________________________________________________
________________________________________________________________________
Have you had any significant training, spiritual or otherwise, that you would like us to
know about? ______________________________________________________________
________________________________________________________________________
________________________________________________________________________
P A R T I C I P A N T R E L E A S E O F L I A B I L I T Y
I affirm that the confidential information, which I have provided, is accurate and complete. I understand that failure to disclose this information could affect my own safety and the safety of those around me, and I agree to hold The Total Human™ harmless if full disclosure of a preexisting medical condition has not been provided. In the event of illness or injury, consent is hereby given to provide emergency medical care, hospitalization or other treatment, which may become necessary. I understand that parts of The Total Human™ programs may be physically or emotionally demanding. I agree to accept full responsibility and assume all risks, including those caused by acts of God, injury, death, and/or loss to my person and/or property knowingly and voluntarily, realizing that The Total Human™ will take all reasonable precautions to minimize these risks.
I knowingly, voluntarily, and irrevocably waive any and all past, present, and/or future injuries, death, or loss, including those caused by acts of God, received while participating in activities conducted by The Total Human™ as a student, participant, spectator, and/or visitor, or in any other manner or form, taking part in the exercises, practices, excursions, and/or demonstrations. I certify that I am physically, mentally and emotionally capable to participate in the program I have applied for despite the rigors and dangers inherent in such undertaking. I acknowledge that the use of video recorders is prohibited.
I understand that at no time during the Vision Quest program will anyone be allowed to stay in the base camp during the Quest other than the Quest protectors/staff - this includes Questers who decide to leave their Quest early. A ride will be provided by a staff member to an outside location were you can arrange hotel accomodations or an early flight home. This is to ensure the undisturbed energy in the protected Quest area for those who remain for the full 4-days and nights, and to ensure that the Quest protectors can focus 100% of their energy on those actively Questing. No refund is given for anyone who chooses to leave early.
I understand that prices, policies and course dates are subject to change without notice, and that The Total Human™ is not responsible for any nonrefundable airfare at anytime, or any travel expenses incurred due to nonchangeable, nonrefundabe airfare. My signature below indicates my acceptance of these terms and my desire to participate in an The Total Human™ program. I also acknowledge that should I cancel, only $150 of the $300 nonrefundable deposit can be transferred (one time only) to another The Total Human™ program within 12 months of the original application. After 12 months, it is no longer transferable. If I do not notify The Total Human™ of my cancellation two weeks before the start of the class, none of the deposit is transferable. No refunds are given after the start of a program. |
Signature:____________________________________________ date: ______________
P H O T O / M E D I A R E L E A S E
I release to The Total Human™ rights to use any photograph or video taken while participating in an The Total Human™ program
to be used as deemed by The Total Human™, including web site, brochure or other advertising.
Signature: ________________________________________ |
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