to:

Size: px
Start display at page:

Download "to:"

Transcription

1 Welcome Pack The Holistic Boot Camp would like to congratulate you for choosing to make positive changes in your life by attending our retreat to transform your mind, body and soul. To make sure that you know exactly what to expect from your stay at The Holistic Boot Camp we have enclosed The Holistic Boot Camp Information Pack. This should cover all details of your stay and answer most questions that you have. Please make sure that you read through this information and if you have any further questions please get in touch. We also require information from you prior to your visit to maximize your results, so that we know exactly what you are looking to achieve from your stay. Please complete the forms and return back to us at least 3 weeks before your stay. Print out and fill in forms. Once completed, take photos and them back to us quoting your full name. to: info@theholisticbootcamp.com The Holistic Boot Camp Team

2 Information Pack ARRIVAL Most of you will be flying into Malaga airport, we will meet you at the airport at arrivals with a board that has your name on it ready to drive you to the retreat for check in. TRANSFER We need to know your flight number and details to make sure your pick up from the airport is arranged. If you have or would prefer to organize your own transfer this is not a problem. Please include this information in your booking form. ACCOMMODATION The Holistic Boot Camp is situated in a luxury private villa on the beach front in Marbella. FACILITIES At check in you will be shown to your suite. Suites are equipped with air con and heating, hairdryer, bath towels & pool towels are also supplied. There are communal areas where you will be able to relax and take advantage of quiet time. Free WiFi is included. Within the beautiful grounds there is a large lagoon pool, outdoor shower and jacuzzi. LIGHTS OUT Lights out is at 10PM in a shared room, unless the whole room agrees to a later time. If you do wish to stay up and read whilst your roommates are sleeping, you may use the communal areas. TRAVEL INSURANCE Please ensure that your travel insurance includes personal accident and cancellation cover in the unlikely event of injury or inability to complete your stay. It is important to check with your insurer that you are covered for this type of activity holiday. If you should sustain any injury and are unable to complete the duration of your stay, this must be claimed through your travel insurance, as we will not issue partial refunds or carry days over. We are happy to write a letter to support your insurance claim and respond to any request for information from your insurers. DISCOVER MORE HOLISTICBOOTCAMPMARBELLA HOLISTICBOOTCAMP 2

3 VALUABLES Only a few rooms have safes so please bring a lockable case if you decide to bring valuables. ALCOHOL AND DRUG NOTICE If you arrive at The Holistic Boot Camp under the influence of drink or drugs, you will be refused entry and will not be able to participate in our programme for health and safety reasons. No refund will be given under these circumstances. During Your Stay ROOM SHARE If you are sharing a room we will introduce you to your roommate, at a chosen stage. If you snore or have difficulty sleeping we advise to bunk on your own. EVENING ENTERTAINMENT With many lounge and chill out areas at the villa, we have a number of movies and relaxing activities planned throughout your stay. DINING Breakfast, lunch, dinner, snacks and drinks are all included at the retreat. Our amazing in-house chefs will be on hand throughout your stay to prepare your delicious healthy meals. We have a large BBQ outside to take advantage of in the evenings, which will make for some tasty dishes that we are sure will not disappoint. If you have any dietary requirements please advise on the form. CHECK OUT On your final day at the retreat, we require you to be checked out of the villa by 10am. DEPARTURE Your transfers will be arranged to ensure you are at the airport in time for your flight. Please check in online to save time. DISCOVER MORE HOLISTICBOOTCAMPMARBELLA HOLISTICBOOTCAMP 3

4 Booking Form The Holistic Boot Camp Team

5 Booking Form Date of Visit: Number Of Nights: Personal Details First Name: Surname: Address: Postcode: Home Phone: Country: Mobile Phone: Flight Details INWARD TRAVEL Departing From: Departure Date: Arrival Date: Flight Number: Going To: Departure Time: Arrival Time: Airline: OUTWARD TRAVEL Departing From: Departure Date: Arrival Date: Flight Number: Going To: Departure Time: Arrival Time: Airline: Transport Would you like to be picked up from the airport? Yes No 5

6 Booking Form All About You What Types Of Exercise Do You Enjoy? Running / Jogging Swimming Cycling Tennis Walking Yoga Team Sports Volleyball Athletics Aerobics Paddle Boarding What Are You Looking To Achieve? Help to Change a Habit Build Confidence Mind Transformation Help With Depression Help With Mental Health Weight Loss Kick Start Fitness Routine Increase Fitness Level Gain Muscle Lifestyle Change Life Goal Attending a Special Event Other: Dietary Requirements Vegetarian Vegan Pescetarians Other: Please advise any allergies: Rate Your Fitness Very Poor Poor Fair Good Excellent Superior 6

7 Medical Declaration The Holistic Boot Camp Team

8 Medical Declaration Form Contact Details First Name Surname Address Postcode Home Phone Country Mobile Phone Occupation Working Hours Emergency Contact Details Name Relationship Contact Number(s) Personal Details Date Of Birth Age Gender Height ft or cm Weight stone/lbs or kg Doctors Surgery Name Doctor s Name Surgery Address Telephone Number 8

9 Medical Declaration Form On-Going Conditions Please tick if you have ever or are currently suffering from any of the below: Allergy - Food / Medicine / Other Anaemia Asthma Arthritis Back Pain Cancer Chest Pain / Discomfort Concussion Chronic Cough Diabetes Deep Vein Thrombosis (DVT) Depression / Anxiety Fainting Spells Frequent Headaches / Migraines Hay Fever Heart Disease Hernia High Blood Pressure High Cholesterol Kidney / Bladder Problems Lung Disease Orthopaedic Problems Pacemaker Pregnant Recent Surgery Seizures / Epilepsy Substance Abuse Stroke Thyroid Problem Other (Please give details) Head Injury If you answered yes to any of the above please explain and give approximate dates: Are you presently taking any medication? If yes, please list medications and specify your condition: 9

10 Medical Declaration Form Are you presently injured or recovering from a recent injury? If yes, please provide details: Are you registered as disabled? Yes No Have you recently undergone any surgery? If yes, please provide details: At The Holistic Boot Camp you will be enrolling on a week-long schedule of high and low intensity physical activities. Although we will try our best to adapt activities to suit all levels of fitness, there is a small margin of people that may not be suitable to participate in these activities. If any of the below statements are relevant to your existing physical state, please consult your doctor before attending to ensure that you are suitable for The Holistic Boot Camp: You are currently taking medication for blood pressure or a heart condition. You have chest pain when carrying out physical activities. You have bone or joint problems that could be made worse by physical activity. You have heart problems. You think you are pregnant. You know of any reason why you should not do physical activity. If you are presently feeling unwell. 10

11 Medical Declaration Form The Holistic Boot Camp Ltd assumes no responsibility for persons who undertake physical activity, and if in doubt after completing this questionnaire, consult your doctor before training or participating. I have read and understood the contents of this document. Name Signature Date Declaration The information that I have provided is, to the best of my knowledge both true and accurate. Full Name(s) Signature Date Disclaimer - The Holistic Boot Camp Limited recognises that physical activities which they offer may in some circumstances create a risk of personal injury or death. The Holistic Boot Camp Limited goes to all reasonable lengths to limit these risks as far as is reasonably possible. Participants in these activities should be aware of and accept these risks and be responsible for their own actions and involvement. Thank You DISCOVER MORE HOLISTICBOOTCAMPMARBELLA HOLISTICBOOTCAMP 11

PAR-Q & LIABILITY WAIVER

PAR-Q & LIABILITY WAIVER PAR-Q & LIABILITY WAIVER Full name: Address: Post code: Mobile: Home phone: Email address: Date of Birth: Occupation: Emergency contact name: Relationship to you: Emergency contact phone number: Tara Blackaby

More information

ENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode: Emergency Contact: Relationship: Phone: What is your main fitness goal?

ENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode:   Emergency Contact: Relationship: Phone: What is your main fitness goal? ENROLMENT FORM Personal Information Title: First Name: Surname: Date of Birth: Sex: Female Male Postal Address: Postcode: Phone: Home: Work: Mobile: Email: Preferred method of contact: Letter Phone Email

More information

PERSONAL TRAINING CLIENT INFORMATION PACKAGE

PERSONAL TRAINING CLIENT INFORMATION PACKAGE WEST VANCOUVER COMMUNITY CENTRE PERSONAL TRAINING PERSONAL TRAINING CLIENT INFORMATION PACKAGE At West Vancouver Community Services, our approach to health and fitness is balanced. Being healthy means

More information

SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017

SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 SAMPLE OF PRE-COURSE OCCUPATIONAL HEALTH QUESTIONNAIRE 2017 PLEASE NOTE THIS IS FOR GUIDANCE ONLY AND IS SUBJECT TO CHANGE PART A Applicant Personal Information PART B Applicant General Health Information

More information

Initial Client Questionnaire

Initial Client Questionnaire Initial Client Questionnaire First Name: Middle Initial: Last Name: How did you hear about my services: Medical History Pregnant: Yes No Nursing: Yes No When was your last physical exam? What are your

More information

DOCTOR REFERRAL LETTER

DOCTOR REFERRAL LETTER DOCTOR REFERRAL LETTER Dear Living Longer Living Stronger Program Co-ordinator, I am recommending my patient/client undertake a monitored Living Longer Living Stronger strength training program that incorporates

More information

Welcome to OPEN Gym. To book an induction please

Welcome to OPEN Gym. To book an induction please Welcome to OPEN Gym Induction Once you have completed your Gym Membership, Standing Order and Liability Disclaimer form as well as the Physical Activity Readiness Questionnaire (PARQ), the next thing you

More information

The StrongWomen Program

The StrongWomen Program A National Fitness Program for Women Cooperative Extension Service 1675 C Street, #100 Anchorage, AK 99501 Leslie Shallcross, M.S., R.D., L.D. Associate Professor of Extension 907-786-6300 Name Address

More information

Nutrition Solutions, LLC Cancellation Policies

Nutrition Solutions, LLC Cancellation Policies , LLC Cancellation Policies Thank you for choosing. Our mission is to educate, inspire and guide you to better health and wellness with balanced nutrition. Due to high demand for appointments we ve had

More information

Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team

Dear Patient, Sincerely, South Texas Bone & Joint Physical Therapy & Rehabilitation Team Physical Therapy & Rehabilitation 601 Texan Trail, Suite 250 Corpus Christi, Texas 78411 Telephone: (361)854-0811 EXT 221 Fax: (361)561-0609 www.southtexasboneandjoint.com Dear Patient, South Texas Bone

More information

FINANCIAL POLICY STATEMENT

FINANCIAL POLICY STATEMENT FINANCIAL POLICY STATEMENT Southern Nassau Physical Therapy, Western Nassau Physical Therapy and Seaside Physical Therapy/DBA Peak Performance Physical Therapy will bill your insurance carrier as a courtesy

More information

EXERCISE READINESS QUESTIONNAIRE

EXERCISE READINESS QUESTIONNAIRE EXERCISE READINESS QUESTIONNAIRE A little bit about yourself... First Name Surname Address Postcode Best Contact Phone No. Your Birthday Email Today s Date Occupation Emergency Contact Phone Number About

More information

PATIENTS DEMOGRAPHICS

PATIENTS DEMOGRAPHICS PATIENTS DEMOGRAPHICS Date: First Name MI Last Name Sex: M or F (Circle one) Age: Address: City: State: Zip Code: Home Telephone: Work Telephone: Cell/Pager No: Date of Birth: Single: Married: Social Security

More information

Jumpstart, Fitness Assessment, & Body Composition

Jumpstart, Fitness Assessment, & Body Composition Jumpstart, Fitness Assessment, & Body Composition Waiver, Release and Hold Harmless Agreement In consideration of permission granted by Purdue University allowing me to participate in Personal Training

More information

Waiver, Release and Hold Harmless Agreement Personal Training Services

Waiver, Release and Hold Harmless Agreement Personal Training Services Waiver, Release and Hold Harmless Agreement Personal Training Services I,, the undersigned, affirm that I am participating voluntarily in Personal Training Services. (Print name) I (together with my parent

More information

Corner on Wellness Chiropractic Center Therapeutic Massage

Corner on Wellness Chiropractic Center Therapeutic Massage Corner on Wellness Chiropractic Center Therapeutic Massage Patient Name Date Address _ City State Zip Phone Email Emergency Contact Name Phone Employer Work Phone Date of Birth Social Security # Is condition

More information

Saleeby Chiropractic Centre, P.A.

Saleeby Chiropractic Centre, P.A. Saleeby Chiropractic Centre, P.A. Stephen M. Saleeby, D.C. Wayne J. Prickett, D.C. Today s Date: / / Chiropractic Intake Z: Name: DOB: / / Age: First MI Last Preferred Name: Address City State Zip Code

More information

Support RP Fighting Blindness by taking part in our 2016 Superhero Run!

Support RP Fighting Blindness by taking part in our 2016 Superhero Run! Support RP Fighting Blindness by taking part in our 2016 Superhero Run! Thank you for requesting a Do it for Charity Superhero Run information pack. We can t wait for you to join us in becoming a real-life

More information

12 Reasons. Why I Want to Reach My Goal Weight

12 Reasons. Why I Want to Reach My Goal Weight WeightLossNYC, page 1 12 Reasons Why I Want to Reach My Goal Weight Name: Date: Before writing your reasons down, give them some thought. It is important that these 12 reasons be true personal goals and

More information

New Patient Questionnaire

New Patient Questionnaire New Patient Questionnaire Name: Primary Care Physician: Date of Birth: / / Home Phone: ( ) Cell Phone: ( ) Why are you seeing a cardiologist? (please answer in detail) Have you ever seen a cardiologist

More information

Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information.

Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. 203-610-2681 New Patient Intake Form Welcome to our practice! Please help us serve you better by taking a few minutes to provide the following information. Name: Last Name First Name Today s date: Address:

More information

WELCOME to the Florence Chiropractic and Wellness Center.

WELCOME to the Florence Chiropractic and Wellness Center. WELCOME to the Florence Chiropractic and Wellness Center. Thank you for choosing our practice for your chiropractic and wellness needs. Please complete this form in ink. If you have any questions or concerns,

More information

UK Stroke Assembly (South)

UK Stroke Assembly (South) UK Stroke Assembly (South) Tuesday 15 March 2016, 9am 4pm Monday 3 July Tuesday 4 July 2017 Stirling Radisson Court Blu Stansted, Hotel, Stirling, Stansted Scotland, Airport, Essex, FK9 4LA CM24 1PP Take

More information

Outdoor School Bogong Parent Consent Form Valid 2016/17

Outdoor School Bogong Parent Consent Form Valid 2016/17 Outdoor School Bogong Parent Consent Form Valid 2016/17 Student s Full Name: Parent/Guardian Consent please circle as appropriate (if left blank we will assume yes is the response): I agree to my child

More information

Exercise Referral Form

Exercise Referral Form Exercise Referral Form To be completed by the referring Health Professional All patient data will be kept securely and in accordance with Data Protection guidelines Patient Details: Title: Mr/Mrs/Ms/Miss/Other:

More information

Weight Loss- Medical History Form

Weight Loss- Medical History Form Weight Loss- Medical History Form Name: Age: Sex: M F Family Physician: Phone: May we contact this practitioner? Yes No Present Status: 1. Are you in good health at the present time to the best of your

More information

MEDICAL INFORMATION: Physician s Name: Phone #: When was your last physical examination?:

MEDICAL INFORMATION: Physician s Name: Phone #: When was your last physical examination?: PERSONAL INFORMATION: HEALTH STATUS QUESTIONNAIRE Name: Phone (hm): (bus): Address: City: State: Zip: Occupation: Male/Female: Age: Height: Weight: Lbs.: Emergency Contact: Phone: Relationship: MEDICAL

More information

PARTICIPANT APPLICATION FORM

PARTICIPANT APPLICATION FORM PARTICIPANT APPLICATION FORM Thank you for your interest in Camp Without Borders! Please carefully read and complete all areas of the application form. Applications must be submitted by the deadline to

More information

Personal Training Program Information and Policies

Personal Training Program Information and Policies Personal Training Program Information and Policies Welcome to the Student Recreation Center s (SRC) Personal Training Program! We are delighted that you chose us as a part of your commitment to health

More information

Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No

Name: Age: Sex: M F. 1. Are you in good health at the present time to the best of your knowledge? Yes No Medical History Form Name: Age: Sex: M F Family Physician: Phone: Present Status: 1. Are you in good health at the present time to the best of your knowledge? Yes No 2. Are you under a doctor s care at

More information

BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage

BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage BOTHELL INTEGRATED HEALTH, LLC Therapeutic Massage Patient Name Date Address City State Zip Phone (home) (cell) Emergency Contact Name Phone Employer Date of Birth Work Phone Social Security # Is condition

More information

Participant Summary Information Sheet

Participant Summary Information Sheet Participant Summary Information Sheet Name: Address: Who was your referral source? (Friend, Doctor, Newspaper, Radio - Please name source) Phone Number: Email Address: Date of Birth: Program Site: Age:

More information

Macclesfield Physio Pilates Health Questionnaire

Macclesfield Physio Pilates Health Questionnaire General Client Details Title:... Name:... Date Of Birth:... Address:... Postcode:... Phone:... Email:... GP s Name:... GP Address:... How did you hear of us? Pilates Aims Why have you decided to commence

More information

Tidelands HealthPoint Stronger Through Movement Program Participant Information

Tidelands HealthPoint Stronger Through Movement Program Participant Information Tidelands HealthPoint Stronger Through Movement Program Participant Information Please Print: Name: DOB: First Middle Last Address: Phone: Street City Zip Email Address: Emergency Contact: Phone: First

More information

Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information

Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY (859) General Information Body Structure Medical Fitness Facility 2600 Gribbin Drive 410 Redding Rd Lexington, KY 40517 (859) 268-8190 General Information Full Name Birth date / / Date / / Social Security # - - Driver s License

More information

Welcome to the new UQ Staff Fitness Program now available exclusively to School of Biological Sciences at The University of Queensland.

Welcome to the new UQ Staff Fitness Program now available exclusively to School of Biological Sciences at The University of Queensland. Welcome to the new UQ Staff Fitness Program now available exclusively to School of Biological Sciences at The University of Queensland. UQ Sport has developed a range of exciting benefits designed to help

More information

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C

Interventional Pain Medicine. P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Interventional Pain Medicine P. Tennent Slack, M.D. Dr. Greg Jackson, M.D. Ben Fleming, PA-C Gainesville Braselton Medical Park 1, Suite 300 Medical Plaza B, Suite 402 1315 Jesse Jewell Parkway 1404 River

More information

We look forward to helping you achieve your fitness goals!

We look forward to helping you achieve your fitness goals! Personal Training Congratulations on your decision to invest in yourself! Our qualified, nationally certified personal trainers will provide you with the right information and right training to help you

More information

AUERBACH CHIROPRACTIC

AUERBACH CHIROPRACTIC AUERBACH CHIROPRACTIC ARTS AND SCIENCE Dr. Gary Auerbach 2730 N. Pantano Road Tucson, AZ 85715 Phone: 520-721-7177 Welcome to the office of Auerbach Chiropractic Arts and Science. In order to better serve

More information

Medical Declaration Form. Important information to read before completing the form:

Medical Declaration Form. Important information to read before completing the form: Administered by Medical Declaration Form Important information to read before completing the form: Pre-Existing Medical conditions Travel insurance only provides cover for emergency medical events that

More information

NUTRITION SCREENING QUESTIONNAIRE

NUTRITION SCREENING QUESTIONNAIRE 1 Name: Date of Birth: Home/cell number: Height: Lowest weight in last 5 years: Physician s Name: Date: Email address: Work phone number: Weight: Highest weight in last 5 years: Physician s Tel. Number:

More information

Outdoor School Bogong Campus Medical Information Form Valid 2015 For Students & Visiting Teacher (VT) to fill in

Outdoor School Bogong Campus Medical Information Form Valid 2015 For Students & Visiting Teacher (VT) to fill in Outdoor School Bogong Campus Medical Information Form Valid 2015 For Students & Visiting Teacher (VT) to fill in This information is intended to assist Outdoor School Bogong in case of any medical emergency

More information

Saddle Up 4 Skeggy Challenge. Welcome Pack. Thank you for taking on the Saddle Up 4 Skeggy Cycle challenge!

Saddle Up 4 Skeggy Challenge. Welcome Pack. Thank you for taking on the Saddle Up 4 Skeggy Cycle challenge! Saddle Up 4 Skeggy Challenge Welcome Pack Thank you for taking on the Saddle Up 4 Skeggy Cycle challenge! We know it s not easy.that s why we think you are amazing for doing so! This pack is designed to

More information

EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age:

EGEA MEDICAL WEIGHT LOSS CENTER. Name: Age: Sex: M F. 6. History of Diabetes? Yes No At what age: EGEA MEDICAL WEIGHT LOSS CENTER Medical History Form Name: Age: Sex: M F Primary Care Physician: Home Phone : Present Status: 1. Are you in good health at the present time to the best of your knowledge?

More information

Thanks again, The BodyEvolver team Fitness Technology Partners, LLC bodyevolver.com

Thanks again, The BodyEvolver team Fitness Technology Partners, LLC bodyevolver.com Thank you for downloading this comprehensive client intake package. It is our pleasure to provide this tested document which we know will help your business. A complete on-line version of this intake package

More information

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's

More information

The failure to bring this information with you may result in the rescheduling of your appointment.

The failure to bring this information with you may result in the rescheduling of your appointment. Alan Koester, MD Steven Novotny, MD John Jasko, MD Viorel Raducan, MD Brock Niceler, MD Thomas Reinsel, MD Chad Lavender, MD Thank you for choosing Marshall Orthopaedics! We will make every effort to ensure

More information

CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM

CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM CONTINUUM CHIROPRACTIC ADULT HEALTH HISTORY FORM Today s Date PERSONAL DATA Legal Name Preferred Name Age Date of Birth Height Weight Home Address City State Zip Home phone ( ) Business Phone ( ) Cell

More information

Patient Name: Date: Address: Primary Care Physician: Online Website On TV In print On the radio

Patient Name: Date:  Address: Primary Care Physician: Online Website On TV In print On the radio 927 W. Myrtle St. Boise, ID 83702 (208) 947-0100 NEW PATIENT INTAKE Patient Name: Date: Email Address: Primary Care Physician: How did you hear about AVT? (Please mark all that apply) Online Website On

More information

Application for Patient

Application for Patient Application for Patient First Name: M.I.: Last Name: Date: Address: City: State: Zip: SS#: - - Age: DOB: / / Male / Female Email: Home #: Cell # Work # Primary Care Physician: Do we have permission to

More information

Holistic INDIGO Therapy client record card Client Appointment

Holistic INDIGO Therapy client record card Client Appointment Holistic INDIGO Therapy Client Appointment be treated with the strictest confidence. PLEASE ensure you complete your Client Identification and only complete the things that have changed since your last

More information

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715

Patient Packet. SSM Health Dean Medical Group Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Patient Packet Weight Management Services 1313 Fish Hatchery Road Madison, WI 53715 Welcome Thank you for your interest in SSM Health Weight Management Services. Please complete the enclosed questionnaire

More information

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays.

Office Hours Our office hours are Monday through Friday 7:30 am to 5:30pm. Our office is closed on all major Holidays. Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints

More information

PATIENT FEE SCHEDULE As of January 1, 2017

PATIENT FEE SCHEDULE As of January 1, 2017 TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is

More information

Linchitz Medical Wellness, PLLC 265 Post Ave. Suite 380 Westbury, NY Phone: (516) Fax: (516)

Linchitz Medical Wellness, PLLC 265 Post Ave. Suite 380 Westbury, NY Phone: (516) Fax: (516) Linchitz Medical Wellness, PLLC 265 Post Ave. Suite 380 Westbury, NY 11590 Phone: (516) 759-4200 Fax: (516) 759-7600 Patient Intake Patient s Name: Last First Middle Address: Street City State Zip Home

More information

Patient Information Form

Patient Information Form Patient Information Form Patient Name: (Last) (First) (MI) Name you prefer to be called: Mailing address: City: State: Zip: Best daytime phone: May we leave a message there? Yes No Alternate phone number:

More information

Please describe, in detail, when the symptoms began:

Please describe, in detail, when the symptoms began: 161 East Mallard Drive, Suite 130, Boise, ID 83706 (208) 947-0100 New Patient Intake Patient Name: Primary Care Physician: Date: Email address: How did you hear about AVT (mark all that apply) Online On

More information

Thank you for choosing Therapy Works to assist you with your current condition.

Thank you for choosing Therapy Works to assist you with your current condition. Therapy Works Welcome Packet Thank you for choosing Therapy Works to assist you with your current condition. Please fill out the enclosed paperwork and bring back with you to your appointment. Important

More information

PATIENT INTAKE FORM Health & Wellness

PATIENT INTAKE FORM Health & Wellness PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address

More information

Join the StrongWomen Program today!

Join the StrongWomen Program today! Join the StrongWomen Program today! Dr. Miriam Nelson, a professor at Tufts University in Boston, Massachusetts, has developed a strength-training program specifically for midlife and older women. The

More information

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone: PATIENT REGISTRATION Patient's Name (Last, First, MI): Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: Employment Status:

More information

Personal Training Health Screening Questionnaire

Personal Training Health Screening Questionnaire RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:

More information

*Your address will be added to our WODIFY system. You may receive correspondence from both WODIFT and Crossfit Toowoomba from time to time.

*Your  address will be added to our WODIFY system. You may receive correspondence from both WODIFT and Crossfit Toowoomba from time to time. Name: Date of Birth: Emergency Name and Contact No: Address: Contact Number: Email Address Occupation: Have you done Crossfit Before? Gender: If so where? *Your email address will be added to our WODIFY

More information

Unplug From Your Daily Life.

Unplug From Your Daily Life. THE YOGA SHACK in COSTA RICA APRIL 21-28, 2018 Unplug From Your Daily Life. Spring is the time of renewal and there is nothing more soul-gratifying than a 7-day retreat that allows you to unplug from your

More information

Subjective Medical History Information

Subjective Medical History Information Page 1 of 8 Date: Patient Account #: Patient Name: Insurance: Date of Birth: History of current condition 1. Which of the following best describes how your injurt occurred? (if your injury is post-surgical

More information

Name: Date: Address: City: State: Zip: Birthday: / /

Name: Date: Address: City: State: Zip: Birthday: / / PERSONAL TRAINING Name: Date: Address: City: State: Zip: Birthday: / / Sex: Male Female Name of Gym: Occupation: Phone (home): Phone (work): Body Weight: Body Fat: Height: Personal Goals 1. Primary Training

More information

2011 Greek Advance Registration Packet

2011 Greek Advance Registration Packet 2011 Greek Advance Registration Packet Greek Advance is the University of Florida s annual leadership retreat for presidents and council exec board members. The curriculum for Greek Advance is derived

More information

(emergency room pain)

(emergency room pain) Welcome to Moving Body Chiropractic! We re glad you re here. Whether you re looking to work on a specific problem or just feel great, this form is the start to your wellness journey! Please take the time

More information

Home intravenous and intramuscular antibiotics

Home intravenous and intramuscular antibiotics Home intravenous and intramuscular antibiotics Children s Community Nursing Service 0161 206 2370 All Rights Reserved 2018. Document for issue as handout. This booklet has been given to you because your

More information

Pro Active Physical Therapy & Sports Medicine

Pro Active Physical Therapy & Sports Medicine Pro Active Physical Therapy & Sports Medicine Consent and Statement of Financial Responsibility 1. CONSENT FOR TREATMENT: I consent to and authorize my physical therapist, occupational therapist and other

More information

A B O U T Y O U D E N T A L I N F O R M A T I O N

A B O U T Y O U D E N T A L I N F O R M A T I O N 1 A B O U T Y O U Full Name: Welcome to Voller Dentistry. We d like to get to know you better so that we can do our best to ensure your total oral health! Marital Status: Spouse s Name: Spouse s Occupation:

More information

History & Review of Systems Screening. Medical History

History & Review of Systems Screening. Medical History History & Review of Systems Screening Patient name: Date: / / Pharmacy name:_ Primary Care Physician: Referring Physician: Height: Weight: R or L handed Medical History Please tell the doctor if you have

More information

Peterson Physical Therapy

Peterson Physical Therapy Peterson Physical Therapy Registration Form Last Name: First Name: Date: Name of parent/guardian (if patient is a minor) Mailing Address: City/State/Zip: Date of Birth: Home Phone: Email: Cell Phone: Cell

More information

Frequently Asked Questions Leadership Institute 2018

Frequently Asked Questions Leadership Institute 2018 Frequently Asked Questions Leadership Institute 2018 Who attends Leadership Institute? Leadership Institute 2018 is open to all members of AOII. International Volunteers, Alumnae Chapter Presidents, Collegiate

More information

Patient Medical History Form

Patient Medical History Form Patient Medical History Form Name: DOB: Sex: M F Street Address: City: State: Zip: Home Phone: Work Phone: Cell Phone:_ Email: Emergency Contact: Phone: Primary Care Physician: Phone: How did you hear

More information

HEALTH FORM. Student s Name Course Code Application ID#

HEALTH FORM. Student s Name Course Code Application ID# HEALTH FORM For NOLS Office Use Only Initial Review OK Detailed Review OK Check Further Date / / AO Initials Student s Name Course Code Application ID# ( ) Daytime or Temporary Phone (circle one) ( ) Permanent

More information

Why Visit a Health and Wellness Retreat?

Why Visit a Health and Wellness Retreat? Wellness Retreat Buying Guide Why Visit a Health and Wellness Retreat? Your guide to finding the retreat that has everything you need to get on your true path to health and wellness. The benefits of a

More information

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC

HEALTH RECORD REASON FOR THIS VISIT ABOUT YOU ABOUT YOUR SPOUSE HEALTH HABITS EXPERIENCE WITH CHIROPRACTIC HEALTH RECORD ABOUT YOU REASON FOR THIS VISIT Name Address City State Zip _Home phone Birth date Cell Phone Age Gender Number of children Employer Work address Work phone Occupation Marital Status Social

More information

F I T N E S S R E T R E A T

F I T N E S S R E T R E A T FIT NESS RE T R E AT INTRODUCTION Palma PT Fitness Retreat will take you away from the dulls of everyday life and replenish your body, making you feel more you. A week away in the beautiful sandy beaches

More information

welcome to wellbridge house

welcome to wellbridge house welcome to wellbridge house welcome to wellbridge house. In this leaflet you will find some information about Wellbridge House and the answers to some frequently asked questions. We hope you will find

More information

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE

PATIENT NAME DATE CONSULTATION QUESTIONNAIRE CONSULTATION QUESTIONNAIRE 1. What is your major symptom? 2. What does this prevent you from doing or enjoying? 3. If this is a recurrence, when was the first time you noticed this problem? How did it

More information

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone:

PATIENT REGISTRATION PERSON TO NOTIFY IN CASE OF EMERGENCY. Name: Relationship: Phone: PATIENT REGISTRATION Patient's Name (Last, First, MI): Date Date of Birth: Age: Sex: M / F Social Security Number: Address: Apt. # City: State: Zip: Home Number: Mobile Number: Work Number: PERSON TO NOTIFY

More information

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES )

- YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) NAME (Please Print) First Name M.I. Last Name DATE of BIRTH / / - YOUR HEALTH HISTORY - (PLEASE COMPLETE ALL PAGES ) Exam Date:,20 PRESCRIPTIONS DRUGS Please Print MEDICATIONS NAMES ONLY NO PRESCRIPTION

More information

YWCA LOWER CAPE FEAR 2815 S College Rd Wilmington, NC (910)

YWCA LOWER CAPE FEAR 2815 S College Rd Wilmington, NC (910) 2815 S College Rd Wilmington, NC 28412 FLOW MOTION REGISTRATION Full Name: APPLICANT INFORMATION Last First M.I. Address: Street Address Apartment/Unit # City State ZIP Code Primary Phone: Email Mobile

More information

Department of Campus Recreation: SouthFit Personal Training

Department of Campus Recreation: SouthFit Personal Training Steps to sign up Step 1: Choose the personal training package that you would like on page 2. Personal training is only available to members of the USA Student Recreation Center. Step 2: Fill out all pages

More information

PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208)

PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID (208) PATIENT QUESTIONNAIRE Boise Location 7272 W. Potomac Drive Boise, ID 83704 (208)884-2922 ***Questionnaire MUST be completed PRIOR to arrival for appointment*** Today s Date / / / / Last First MI DOB Referring

More information

Lifestyle & Pre-diabetes Questionnaire

Lifestyle & Pre-diabetes Questionnaire Please complete this questionnaire. The time you take to provide this information will help your health care team work better for you. General, Medical and Health Information Date: Name: Age: Race: Current

More information

Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax:

Nash Sleep Disorders Center 250 Medical Arts Mall Suite C Rocky Mount NC Phone: Fax: Appointment Date: Arrival Time: *Please give at least 24 hour notice if you are unable to keep your appointment or need to reschedule. 1. Patients will need to bring pictured identification, insurance

More information

Gymnasium Sign In/Sign Out Sheet. Please sign in before commencing your workout

Gymnasium Sign In/Sign Out Sheet. Please sign in before commencing your workout Gymnasium Sign In/Sign Out Sheet Please sign in before commencing your workout Name Date Time In Time Out Signature Pre Activity Questionnaire Name: 1) Have you undertaken an exercise program before? Yes

More information

New Patient Form Welcome!

New Patient Form Welcome! New Patient Form Welcome! Last First Middle Initial DOB Address City ST ZIP Phone (H) (C) Email Occupation Employer Relationship Status S M W D Spouse s Name DOB Children s Names and Ages Have you had

More information

medical history Questionnaire

medical history Questionnaire Surname: medical history Questionnaire Please take a few minutes to answer the following questions carefully as this assists us in preparing for your assessment. The information from this Questionaire

More information

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State

Patient information. Today s Date. Patient s Name D.O.B. Street Address Apt. No. Home Phone # Work Phone # Social Security # DL # State Patient information Today s Date Patient s Name D.O.B Street Address Apt. No. City / State / Zip Code Home Phone # Work Phone # Social Security # DL # State Sex Female Male Marital Status Single Married

More information

What we need from you:

What we need from you: What we need from you: Completed Camper Application 2019 - If we are missing any information, signatures, or the deposit; we will return the application. Applications will not be accepted after July 19,

More information

Client Medical Consultation / Treatment Record

Client Medical Consultation / Treatment Record Client Medical Consultation / Treatment Record Title (Mr/Mrs/Ms/Miss): Client Name: Address: Physician Name & Surgery: Physician Contact No: Tel Home: Tel Work: Tel Mobile: E-mail Address: Postcode: Age:

More information

CHALLENGE EVENT Welcome Pack

CHALLENGE EVENT Welcome Pack CHALLENGE EVENT Welcome Pack Thank you for taking on a challenge! We know it s not easy for anyone to tackle a marathon, climb a mountain or even a Skydive! that s why we think you are amazing for doing

More information

ADVANCED NUTRITIONAL CONSULTING

ADVANCED NUTRITIONAL CONSULTING ADVANCED NUTRITIONAL CONSULTING Steven Salyers DC MS CNS DACBN Certified Nutrition Specialist, Diplomat American Clinical Board for Nutrition Last Name: First Name: Street Address: City: State: Zip: Phone:

More information

Additional details about you What is your ethnic group? Name of next of kin \ Emergency contact

Additional details about you What is your ethnic group? Name of next of kin \ Emergency contact Thank you for applying to join The Hedges Medical Centre. We would like to gather some information about you and ask that you fill in the following questionnaire. You don t have to supply answers to all

More information

Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip: address: Home Phone Cell Phone:

Patient # (assigned by office) Full Name: Social Security # Address: City: State: Zip:  address: Home Phone Cell Phone: We appreciate the opportunity to help you get back to the health. The more accurate and complete the information you give us, the better service we can give you. Date: Patient # (assigned by office) Full

More information

APPLICATION PACK CHECKLIST

APPLICATION PACK CHECKLIST APPLICATION PACK CHECKLIST Instructions Please tick if the relevant section is completed and included: Employment Application WorkCover Declaration Immunisation Record Form Record of Vaccinations Received

More information

MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED

MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED MASSAGE INTAKE FORM PATIENT S PREFERED NAME DATE COMPLETED Patient Information Name: DOB: / / Gender: M F Home Address: Home Phone: City, State, Zip: Work Phone: Email Address: Cell Phone: I do not want

More information