Holistic Questionnaire

Jill Ayn Schneider, Director of Circle of Life Holistic Programs

15492 Lakes of Delray Blvd., Suite 106

Delray Beach, FL 33484

Tel: (561) 638-8873 Fax: (561) 638-4938

Please take some time to read this questionnaire/release form and fully answer these questions and mail to Jill Schneider at the address above.

Date:..................................................Dates and Location of Retreat:…………………………………..

Name...................................................................M/F.........................DOB.................Age..........

Height.................................................Weight.............................................................................

Address......................................................................................................................................

.............................................................................................................ZIP code........................

Tel No......................................................day.............................................................evening

E-mail Address…………………………………. Occupation……………………………………….................

Name, Address and Tel. no. of your GP:

Current Treatments: Please list all medicines or treatments you are currently taking/having. Please include vitamins, other therapies and medicines, as well as all prescribed medicines from your GP.

Recent Treatments: Please list any medicines or treatments that you have tried over the past few months, but have discontinued.

Past Medical History: Childhood illnesses? Please list all significant illnesses, accidents, operations or health problems, with dates, only list them, no details needed here.

Troublesome Symptoms: Please list your main symptoms or problems. No details needed here, just a list.

Minor Symptoms: Please list any other symptoms you have, even if they seem minor.

When did you last have any blood tests?

Who else is involved in your Health Care? e.g. Consultants, nurses, physiotherapist, complementary health practitioners etc

Allergies

Have you ever smoked? Do you smoke now?

Family illnesses: are there any illnesses, which run in your family?

Do any of your relatives suffer, or have suffered, from any of the following? TB, cancer, diabetes, thyroid disease?

Home situation: Who lives in your household? (including pets!)

Goals for your Body, Mind and Spirit:

Patient Release:

I hereby release Jill Ayn Schneider, Director of Circle of Life Holistic Programs from any and all liability whatsoever associated or connected to my use of any and/or all of the natural healing protocols recommended to me, which could possibly create adverse effects. I hereby state that I am at least eighteen years of age and I am fully competent to make my own health care decisions. I am aware of the potential side effects associate with detoxification through juice fasting.

I understand and acknowledge that treatments and opinions differ among the very best, well-trained persons. I understand and acknowledge that there is no (nor can there be), any implied warranty to me, that treatments may benefit one person and not another, that these opinions may differ from time to time, depending upon many factors. I understand the risks.

I state that I have had a physical examination by the physician whose care I am under within the last twelve months.

By signing this waiver, I agree to release liability and hold harmless the therapists and holistic consultants from all causes of action, suits, penalties, liens, judgments, liabilities, obligations, losses, actual or consequential damages and actual or threatened claims which may arise at any time by reason of relating to, arising directly or indirectly out of any matter whatsoever related to this cleansing program consisting of juice fasting, yoga, massage and colon hydrotherapy. (FL MA#9313)

Jill Ayn Schneider, LMT, Director of Circle of Life Holistic Programs reserves the right to change this disclaimer and the consultation form at any time, including the price of consultations.

This agreement represents the complete and entire agreement between Jill Ayn Schneider, LMT, Director of Circle of Life Holistic Programs and me. I have read and understood the above-referenced "Patient Release/Disclaimer". I authorize and accept the proposed terms of care. I declare that I understand all the terms and conditions herein.

Name:..................................................................Date....................................................................................