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Application Process


Thank you for your interest in Our Home Health Retreat. Applicants are required to submit the completed application form as well as recent medical records (lab reports, CAT scans, x-ray reports, summaries or other pertinent information) two weeks before the session begins. **Please allow for two weeks for a response to a consultation form once we receive it for opportunity to review.**  

Health Guest/Student Registration Form (482 KB)

Conditions of Acceptance

Our Home Health Retreat, as indicated in our disclaimer, is a learning facility where guests are admitted as students to learn to maintain or recover their health and medically take charge of their own lives. We are not a medical facility or treatment center, nor do we give medical advice.

To be admitted here health guests/students must:

You are not considered confirmed and no space is reserved for you until we receive your completed health questionnaire along with a $500.00 dollar deposit. These must be received no later than two (2) weeks prior to your arrival at our health facility to begin the health session you registered for.

Your lifestyle program will be based on the health questionnaire and whatever additional information you may be requested to provide, such as blood work, x-rays, CT scans, discharge summaries, etc. We make no promises or guarantees of healing.

The program that is developed for you will focus on your major health concerns. We recognize that you might have other minor aches or pains. However, by addressing the major concerns, the smaller ones will be eliminated in the process.

information, you will be advised to seek assistance elsewhere. Your donation will be non-refundable. No refunds will be given for health guests choosing to leave before the session ends. We welcome the privilege of serving you and pray that our Heavenly Father will bless you in your quest for better physical and spiritual health.

I Have Read And Agree To The Standard And Regulations.


First Name
Last Name
Street Address
Apartment, suite, unit etc.
Country
City
State / Province / Region (if applicable)
Postal Code / Zip Code
Home Phone
Cell Phone
E-mail Address
Birth Date
Birthplace
Nationality
Marital Status
                        
Sex
Height
Occupation
Religion
Recreational Activities
In case of emergency contact
Phone
Which program will you be attending?
         
When do you plan to arrive and how?
How did you learn about Our Home Natural Health Reatreat?
What illnesses do you want help dealing with?

FAMILY HEALTH INFORMATION

(List family memebers "spouse, father, mother, brother/sisters, and/or children")

First name
Last name
Relation
Present age, age at death
If living, health (good, fair, poor)
If deceased, cause of death
First name
Last name
Relation
Present age, age at death
If living, health (good, fair, poor)
If deceased, cause of death

PERSONAL HISTORY

No. of Pets
What Kind?
Any Inside?
Type of Home
Past Occupations
Habits
Sleep (hrs/night)
Do You Have Difficulty Sleeping?
         
Do You Smoke?
    
If Yes, what?
How Much?
Do You Drink Caffeine Containing Drinks?
         
How Much?
Do you drink alcoholic beverages?
If so, please indicate how much?
Are You on a Special Diet?
    
What Kind of Diet?
Have you suffered any injuries to the head, chest, abdomen, back or any broken bones?
Have you Lost Weight in the past year?
    

IMMUNIZATIONS

List all immunizations you have received, and the date

Immunization
Date

ALLERGIES

List any food or other allergies

MEDICINES

(Prescription or over the counter)

Are you regularly taking any medicines now?
    

Have You Ever Taken (Check All That Apply)

Insulin
    
Thyroid Med
    
BP Medicine
    
Birth Control Pills
    
Cortisone
    
Hormones
    
Tranquilizers/ Sedatives
    

DEVICES (check)

Do You Have Any Internal Medical Devices, (i.e. pacemaker or a defibrillator)?

OPERATIONS

Have you had any surgical procedure? If yes, what kind and when?

Surgery
Date

Please check everything on the following list that you normally use in your diet.

Flesh foods (chicken, pork, beef, seafood), Dairy Products, Sugar, Refined foods (white flour, white rice, white bread, white sugar),Caffiene (Chocolate, soda), Carbonated Beverages, Spices (mustard, vinegar, cinnamon, etc)

Do you ever eat between meals?
    
Just before bedtime?
    
How many meals a day do you eat?
Normal mealtimes?
Approximately how much time do you spend eating at mealtime?
Do you chew your food thoroughly, so that it is the consistency of cream?
    
Do you eat fruits and vegetables at the same meal?
    
How many glasses of water do you drink a day?
How often are you bothered with constipation?
Diarrhea?
Are your bowel movements regular?
    
How frequent?
How often do you have hard stools?
Soft stools?
Rectal bleeding??
How often do you urinate?
Is it normal for you to leave your arms or legs bare at times?
Do you often have cold hands or feet?
    
Tingling sensations?
How often do you have indigestion?
Gas??
What is your normal bedtime?
Rising time?
Do you rest during the day?
         
Do you exercise out of doors with any regularity?
    
What do you normally do for exercise?

DESCRIBE YOUR PERSONALITY TRAITS

Please check everything on the following list that applies to you:

(Outgoing, withdrawn, reserved, shy, self-confident, self-conscious, quiet, enthusiastic, calm, easily excitable, friendly, optimistic, pessimistic, compassionate, practical, awkward, poised, well-coordinated, organized, disorganized, perfectionist, idealistic, dependable, undependable, efficient, economical, sensitive, moody, depressed, impetuous, excessive worry, aggressive, decisive)

Do you enjoy being around other people most of the time? If so, what type of people do you prefer?
What are your main interests or hobbies?
Do you have confidence that God is the only source of true healing?
Which of your weaknesses would you like to see strengthened?

DIAGNOSED DIFFICULTIES BY DOCTORS

What difficulties have you been diagnosed with by your doctor?
Please review the listing found below and indicate appropriately.

LIST OF CONDITIONS

(Migraine Headaches, Epilepsy or Convulsions, Stroke, Glaucoma, Cataracts, Blindness (either eye), Deafness, Asthma, Hay Fever, Chronic Bronchitis, Emphysema, Tuberculosis, Abnormal Chest X-Ray, Heart Murmur as an adult, Abnormal Electrocardiogram, Enlarged heart, Heart Attack, Rheumatic Fever, Angina, High Blood Pressure, Gall Stones, Hepatitis, Cirrhosis of Liver, Stomach or Duodenal Ulcer, Abnormal Stomach X-ray, Colon or Bowel Trouble, Rectal Trouble, Hemorrhoids or Piles, Dysentery or Serious Diarrhea, Kidney or Bladder Infection, Kidney Stones, Other Kidney disease, Poor Blood Clotting, Diabetes, Gout, Overactive Thyroid, Under active Thyroid, Goiter, Parkinson's, MS, Varicose Veins, Arthritis, Polio, Phlebitis, Venereal Disease, Anemia, Insulin, Recurrent boils, Other skin disease, Serious depression, Serious Emotional Problem, Nervous Breakdown.)

WOMEN

(Menstrual difficulties, Ovarian Cyst, Other GYN Problems, Cystitis, Mastitis, Breast Cancer)

FAMILY HISTORY

Please indicate what diseases your blood relatives have suffered from?
Include who that relative was (i.e. brother, sister, mother).

(Cancer, including leukemia, Tuberculosis, Diabetes, Heart Trouble, Heart Attack, High Blood Pressure, Stroke, Epilepsy, Convulsions or fits, Bleeding tendency, Asthma, Allergies, Liver Disease, Migraine Headaches, Alcoholism, Emphysema/lung disease, Stomach or duodenal ulcer, Kidney Disease, Glaucoma, Sickle Cell Anemia)

SYSTEM REVIEW

Please review the listing found here (hyperlink this to the list of ailments) and indicate what
complaints you may be suffering from?

HEAD: (Blurred vision not corrected by glasses, double vision, light flashes, halos around lights, pain in your eyes, ear pain, drainage from ear, hearing difficulty or deafness, buzzing or ringing in ears, sinus trouble , difficulty swallowing , mouth or tongue problem , persistent hoarseness and Other, explain.)

SKIN: Changing mole, Rash, Yellow skin, Other skin problem , explain.

NECK: Swelling, lumps, stiffness, other Explain

CHEST, HEART, LUNGS: Shortness of breath, Poor exercise tolerance, Fluttering of heart, Unusual heartbeat, Chest pain or pressure attacks, Frequent cough, Coughing up blood, Wheezing swollen ankles, Other, Explain.

GASTROINTESTINAL: Poor appetite, Indigestion or heartburn, Nausea or vomiting, Vomiting blood, Abdominal pain of swelling, Blacktar-like bowel, movements, Abdominal cramps, Other, Explain.

KIDNEY: Blood in urine, Difficulty passing urine, Pain or burning while urinating, Difficulty controlling urine, Getting up at night to urinate, Other, Explain.

GENITALIA WOMEN: Breast lump, Discharge from nipple other breast problem, Vaginal bleeding or spotting (not with periods), hot flashes, pain with intercourse, possibly pregnant, change in periods, pain not associated with periods, other Explain.

GENITALIA MEN: Breast lump, Discharge from penis, Sore on penis, Lump in testicles, Difficulty having erections, Other Explain:

NEUROMUSCULAR: Weakness in arm or leg, Difficulty with balance, Dizzy spells, Fainting spells, Speech difficulty, Other, Explain.
BONE/JOINTS: Painful joints, Swollen joints, Loss of muscle strength, Lump or swelling in muscle, Lump on bone, Back pain, Other, Explain.

ENDOCRINE: Thirsty all the time, cold most of the time, too warm most of the time, unusually tired or sluggish

PSYCHOLOGICAL

Do you find your life:: generally unsatisfactory, too demanding boring, satisfactory?

Do you worry about: money, job, marriage, home life, children?

Do you: Cry easily, Feel inferior to others, Feel shy, Feel things often go wrong, Often feel depressed, Have irrational fears, Feel anxious or upset.

Have you: Seriously considered suicide, attempted suicide

ENDOCRINE: Thirsty all the time, cold most of the time, too warm most of the time, unusually tired or sluggish

CHIEF COMPLAINTS

What are your chief medical complaints?
Review the list below and indicate what symtpoms you are experiencing. Use 1,2,3 or 4 to indicate the
severity of the problem - 4 being the most severe. Please note whether the problem is present,
past or both."

abnormal thirst, highly emotional, acid Foods, hoarseness, frequent, Acne, hunger between meals, Adenoids, impaired hearing, afternoon headaches, increased amount of urine, afternoon "yawner", can't decide easily, aging rapidly, can't gain weight, air (swallow air), can't start in AM before coffee, allergies-asthma tendency, can't work under pressure, aluminum cooking utensils, cataracts, ankles swell in evening, chemical or spray poisoning, ankles swell in morning, chemicals in environment, appetite excessive, chronic fatigue, appetite reduced, cigarette cough, Armed Forces Syndrome, circulation poor, arthritic tendencies, sensitive to cold, awaken after few hours asleep, cloudy urine, hard to get back to sleep, coated tongue, bad breath, cold sweats often, bad dreams, color blind, bitter, metallic taste in mouth in AM, constipation, common, black or bloody stools, constipation, diarrhea –alternating, bleeding gums, convulsions, bloating of intestines, crave candy or coffee in afternoon, blurred vision, crave salt, blushes easily, crave sweets or snacks, body odor bad, crawling sensation of skin, bottle fed, cries easily/no apparent reason, bowel movements painful, cuts heal slowly, breathing irregular, damp weather bothers, brittle fingernails, dandruff, brown spot or bronzing of skin, dark glasses, bruise easily "black & blue spots", day dreamer, burning feet, daytime sleepiness, burning or itching anus, decreased amount of urin, burning on urination, decrease in appetite, burning stomach sensations, dental caries, relieved by eating, depressed, "butterfly" stomach, cramps, difficulty swallowing, dwell on past, digestion rapid, increased appetite, dizziness, eat often or get hunger pains or, drug reaction, Faintness, dull pain in chest or radiating to, eat rapidly, increase in weight, eat slowly, indigestion 1/2-1 hour after eating, eat when nervous, indigestion 3-4 hrs after eating, eyelids and face twitch, indoor occupation, eyelids swollen, puffy, smoky urine, eyes bulge, intestinal trouble, eyes or nose watery, intolerance to heat, eye strain, inward trembling, exhaustion-muscular and nervous, irritable and restless, extremities cold, clammy, irritable, annoyed easily, fainting spells, itching skin and feet, faintness if meals delayed, joint stiffness in evening, falling hair excessive, joint stiffness in morning, fatigue easily, keyed up, fail to calm, fatigue, eating relieves, lack energy, fearful, laxatives used often, fever easily raised, light colored stools, fluoridated toothpaste, loud talker, fluoridated water, loses temper easily, food poisoning history, low back pain, flank, frequent urination, low blood pressure, gag easily, lower bowel gas several hrs after eating, gas shortly after eating, magnifies insignificant events, get drowsy often, mentally alert, quick, going crazy sensation, mentally sluggish, goose flesh common, moods of depression, "blues" / melancholy, goose flesh seldom, mucous colitis, greasy food intolerances, muscle cramps, worse during exercise/ "charley horses", gum chewer, muscle-leg-toe cramps at night, hair coarse, falls out, muscle twitching, hair treatments, sprays, etc., nails weak, ridged, split, hallucinations, Nausea, hands and feet go to sleep easily, nerve pains, Numbness, nervousness, hand tremor, opens windows in closed room, hard to awaken, overeating sweets upset, hate to be criticized, overexertion reactions, headaches upon arising -wears off during the day, overwork, nose bleeds frequently, pain between shoulder blades, heart palpitates for no reason, perfectionist, hiccups frequently, perspiration increases, high altitude discomfort, perspiration decrease.

Do you represent any food and drug, Medical or Government Organization?
    

I hereby give my permission and consent that my case records may be used for research and educational purposes.

Your full name
Date

LIFE SCRIPT WORKSHEET
Describe Yourself

Describe Your Father
Describe Your Mother
What makes you feel most happy, loved, successful and glad to be alive?
What makes you feel most unhappy, unloved, mad, disgusted, etc.?
When you were little, who did you go to with your biggest troubles?
Why?
When you were little, what did the family usually talk about at the dinner table?
Nowadays, what is your main bad feeling?
What is wrong with your life?

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