Path of Life Healing Center

10-Day Detox Retreat
Guest Assessment Form

Please Note:

Please Note: The information received during this program and/or any services, or any future programs or interactions, and/or any services, is for general education and community service, and is not intended to supply specific medical care or advice. No medical care, treatment, or diagnosis is provided during this program, and/or services. It is advisable to consult with one’s personal health care provider before implementing any lifestyle changes.

I release Path of Life Healing Center, or associated persons, facilities, and/or organizations from any and all liability. Participation in this program indicates acceptance of all these and additional terms found in our Liability Release Waiver.

Signature:

Clear

Number of days

Customize Your Stay:

Your guest is half the cost of your stay. Your guests will receive lodging and food/juices only. Does not include therapies.

Does your stay include a guest?

Yes

General Information:

Full Name *

Email *

Phone *

Address

Street address

City

State

Country

Postal code

Emergency Contact Information:

Name
Email
1st Phone
2nd Phone

Vital Information:

Birthdate
Age
Gender
Height
Weight
Marital Status

Religious Affiliation:

How Long?

How Did You Find Us/Who Referred You?

List any health concerns or diagnosis you have (physical, mental, social, or spiritual):

Specify your top three areas of concern you would like this program to address?

Please clearly list any food (allergies, sensitivities, intolerances) and environmental allergies, and/or allergies of any kind (please be specific).

When did you last consult a physician?

Are you currently being treated for any ailments? Yes /No If yes, which ones?

Please list any surgery that you have had (include date/s):

How long have you been trying to overcome your health challenges?

What have you tried on your own? Did it work? What was your biggest obstacle?

Do you have any family history of disease? If so, please list all.

Do you have any skin rashes or feet issues such as athlete’s feet, eczema, ring worm, etc…

Are You Vaccinated?

Yes

Name of the Vaccination?

Name of any boosters received and how many?

How many children do you have? What are their ages? Are they healthy?

Please fill in your lab values. You can upload your latest labs here.

Hemoglobin A1c
Glucose
Sodium
Potassium
Cholesterol
BUN
Creatine
Protein
C-Reactive Protein

Upload latest labs here:

A Hair Mineral Analysis Test is a test using a sample of your hair to determine your micronutrient status and if you have heavy metals that can drain your health and energy and cause chronic illnesses. Let us know if you would like that test. It takes about 10 days to get the results after they receive your hair sample.

If you don't have labs to upload, please list any other values that are out of range.

Are you currently suffering from any eating disorders? (please circle all that apply):

Bulimia
Anorexia
Binge Eating
Other

Do you have body dysmorphia or other related concerns?

Please mention any symptoms you are having not mentions in previous section:

Are you experiencing any addictions or substance abuse? Yes / No (If yes, please list below):

Do you suffer from any of the following emotional / mental disorders? Give a little description:

Depression
Co-Dependency
Phobias
Anxiety
OCD
Manias
Bipolar
Dementia
Schizophrenia
Neurosis
Social Disorders

Please list all medications and / or pills, prescription or otherwise, you are currently taking (or have taken in the past 60 days): List usage, dosage and what they were/are prescribed for:

Med 1
Med 2
Med 3
Med 4
Med 5
Med 6

If there are more than 6, list them here:

Please list all supplements and / or herbs that you are taking or have taken in the past 60 days on a consistent basis (vitamins, minerals, nutritional drinks, etc.).

Supplement 1
Supplement 2
Supplement 3
Supplement 4
Supplement 5
Supplement 6
Supplement 7

If there are more than 7 please list the rest here:

What do you want to achieve by the end of your session? Do you have any questions or concerns?

Welcome Aboard

Start Your Application Process Here!