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					                  Customer Services – Health Intake Form
                      Tree of Life Rejuvenation Center
                      686 Harshaw Road, PO Box 778, Patagonia, 85624
                    PH 866 394 2520 FAX 415 598 2409 www.treeoflife.nu

PLEASE FILL OUT AND SEND ASAP This is important even if you have submitted
one for previous programs. Knowing your recent health condition and your health
history gives us a better understanding of how to support you during your fast. This
document must be received in order to confirm your fasting reservations.
PLEASE RETURN VIA EMAIL TO INFO@TREEOFLIFE.NU or FAX ATTENTION: front desk

                                       STAY DETAILS
   PROGRAM TITL E

    DATES OF STAY



                                    BIOGRAPHIC DATA
    NAME

   EMAIL

  MAIL ADD
   STREET
 CITY, STATE                                    HOME PH #

     ZIP                                        CELL PH #



                                  EMERGENCY CONTACT
EMERGENCY CONTACT NAME

RELATIONSHIP

PHONE



                                GENERAL INFORMATION
DATE OF BIRTH:

Occupation:

Gender:

Height:

Weight:




                            FASTING BACKGROUND INFORMATION
Have you ever fasted before?
If so, how long?
What did you fast on (water, juice, etc.)?


                  Tree of Life Rejuvenation Center - Customer Service Department
   TOL Health Intake Form                     Page 1                               3/8/2010
                    Customer Services – Health Intake Form
                                         HEALTH STATUS

   Please Indicate Any Condition Below That Applies To You Now (N) Or In The Past (P).
            Condition                 Now/Past           Date Diagnosed/Current Status
Arthritis                              N        P

Asthma                                 N        P

Bone or Joint Problem                  N        P

Bowel Disorder (chron's, colitis,      N        P
etc.)
Cancer                                 N        P

Candida Albicans (yeast infection)     N        P
Cardio-vascular disease/heart          N        P
attack (or any heart condition)
Diabetes                               N        P

Dizziness or Loss of Balance or        N        P
Consciousness
Epilepsy or seizure disorder           N        P

Hypertension/high blood pressure       N        P
Hypoglycemia (low blood sugar          N        P
Prescription Drugs                     N        P
Liver Disease (Hepatitis, Hepatitis    N        P
C)
Nervous system disease (M.S.,          N        P
Parkinson's)
Are you Pregnant or Suspect            N        P
Pregnancy?
Prescription drugs (please list)       N        P




Ulcers                                 N        P

Urinary tract disorder (kidney,        N        P
bladder)
Weight loss or gain                    N        P


                                       PHYSICAL HEALTH
Do you have chest pain during physical activity?

Do you experience chest pain, in the last month,
when not doing physical activity?
Do you have a hearing/vision or structural condition
that limits activity in any way?
Do you weigh more than 20lbs under the normal
weight charts or previous healthy weight?
If so when/what treatments have you undergone?



                    Tree of Life Rejuvenation Center - Customer Service Department
    TOL Health Intake Form                          Page 2                           3/8/2010
                    Customer Services – Health Intake Form

                                             FOOD NOTES
Do you have any food sensitivities?
If so, what foods?
Do you currently experience food binges? If so, what
are your trigger foods?
Do you have a history of an eating disorder
(anorexia, bulimia, or compulsive over-eating)?
Do you have a current eating disorder?

                                DRUG NOTES
 CURRENTLY USING ANY OF THE FOLLOWING?    DAILY AMOUNT, FREQUENCY & TYPE
 Caffeine

   Alcohol

   Nicotine

   Recreational Drugs

   Medicinal Drugs
Have you had a history of drug or alcohol abuse?
Are you under current treatment?



                                          PSYCHOLOGICAL
Panic attacks or frequent bouts with anxiety – Past &
Present?
Have you been in psychotherapy for an issue? If so
was there a diagnosis?

Have you ever been hospitalized for psychiatric or
addiction reasons? If so, when and for what issues?
Medications you are currently taking? Medications
you previously took?

                                               OTHER
Are you under a physician's care for any reason not
noted on this form? If so, please describe.
What’s your main reason for coming?




Is there anything else you would like to share?




                                       GUEST CONTRACT

                    Tree of Life Rejuvenation Center - Customer Service Department
    TOL Health Intake Form                         Page 3                            3/8/2010
                   Customer Services – Health Intake Form

I understand that the fasting, cleansing and rejuvenation programs stimulate the
body to release held toxins and that I may experience one or more temporary
symptoms such as: headache, fatigue, nausea, muscle weakness, light
headedness, high energy, euphoria, clarity of the mind and the senses, as well as
emotional release.

I also understand that there are various detoxification modalities such as saunas,
yoga and taking daily enemas that are recommended and instructions and support
will be given. Because the Tree of Life Rejuvenation Center is educational in
nature, I understand that they are not set up to attend to the seriously ill (as
noted in our medical policy**). I have provided the above information truthfully.

Date:

Signature*


       Signature: Agrees that you understand/ agree to all the statements on this
        document and our medical policy. If you are emailing this back to us, your
        email to us serves as your signature.
       This document will be placed in a chart we create for you and used by our
        clinical nurse and the doctor to help them determine what level of care and
        attention required during your retreat program.

                             ** Tree of Life Medical Policy

The Tree of Life is not set up as a 24-hour medical crisis center; we are not equipped to
handle urgent medical care needs and are not in possession of a defibrillator machine or
emergency equipment. We are not a rehab center for coming off drugs and/or alcohol and
are not setup to provide special care for clients who have special physical, physiological or
emotional needs. If you are in need of assistance in getting around our property, or other
special care, we require that you bring someone with you to help meet your special needs.
We require that all clients disclose any significant health issues prior to coming to the Tree
of Life. Anyone at high risk for needing emergency medical care should not come to the
Tree of Life unless this risk has brought to the attention of Dr. Cousens. If while staying at
the Tree of Life, due to health conditions, our medical staff determines that a client is in
need of urgent medical care, the client is required to pay any or all ambulance and hospital
fees.

Key Medical Points

   Our focus is helping people build the immune system. This focus indirectly helps with all
    degenerative diseases.
   We do not claim to be a cancer or AIDS clinic, or that we cure cancer or AIDS.
   We are not a drug or alcohol rehabilitation center.
   Guests are required to be off of any drugs at least 3 months prior to coming to the Tree
    of Life
   We make no healing claims.
   It is the responsibility of the individual to take the necessary steps towards excellent
    health and vitality.
   These steps may involve using other health modalities provided at the Tree of Life.




                   Tree of Life Rejuvenation Center - Customer Service Department
    TOL Health Intake Form                     Page 4                               3/8/2010

				
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