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Home
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C.H.E.A.P.
Detox Online Course
Detox Wellness Programs
Media
Social Media
LSR Live Podcast!
Health Blog
Recipes
Support Us
Contact
Store
Health Form for Wellness Companion
Select One
*
Please select the dates of the program you are registered for.
October 13th-20th
November 10th-17th
December 8th-15th
Name
*
First Name
Last Name
Email Address
*
Street
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Mobile Phone
*
Country
(###)
###
####
Alternate Phone
Country
(###)
###
####
Gender
*
Male
Female
Weight
*
Height
*
DOB
*
Age
Ethnicity
*
Emergency Contact
*
Emergency Contact must be someone NOT at the retreat with you.
First Name
Last Name
Relationship with Emergency Contact
*
Emergency Phone
*
Country
(###)
###
####
Occupation
How did you learn about Living Springs?
Do you have any type of allergies? If so, please list them
*
Are you developing your mental and spiritual life by daily study, meditation and prayer?
Yes
No
What is your Religious Affiliation?
Are you involved in some type of activity in which you are helping others?
Yes
No
Are you following any special diet?
*
Yes
No
Explain what type
Do you eat animal products?
*
Yes
No
If so, what kind?
Do you eat dairy products?
*
Yes
No
If so, what kind?
How often do you eat tossed green leafy salad?
*
How often do you eat steamed/cooked vegetables?
*
How often do you eat fruits?
*
What type of foods do you usually eat?
*
IMPORTANT: This assessment form is intended for educational purposes only, to assist the individual in learning how to preserve their own health. It is not the intention of this evaluation to diagnose or to prescribe any medication, treatment or modality for any physical or mental disorder, disease, ailment, complaint or anomaly. Therefore any use of the information obtained from this evaluation, is at the sole discretion of, and in response to the direct request made by the individual whose name is signed on this form.
*
Signature - Please type your full name:
Date
*
MM
DD
YYYY
Thank you!
