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Consultation

Wellness Consultation

Your health history and lifestyle help us get to the root of the problem. Once accepted for a retreat, complete this consultation application too.

Consultation application

Questions marked * are required. Your answers go only to our wellness team. Payment is made by card at the end.

Your answers are private: only our wellness team can read them.

1. Contact Info
2. ID Details
Marital Status *
Sex *
3. Medical History
4. Medication
5. Gastrointestinal Conditions
Do you have indigestion? *
Do you have gas? *
Do you have bloating? *
6. Elimination Conditions
Do you have diarrhea? *
Do you have constipation? *
7. Vision Conditions
Do you wear eyeglasses? *
Do you wear contact lenses? *
8. Other Conditions
What health ailments, illnesses or challenges have you suffered with in the past and/or are currently suffering with?
9. Godly Trust
Do you often feel guilty about past mistakes? *
Do you worry about the future? *
Do you suffer with depression? *
Do you have stress? *
Check all of the following categories which cause stress: *
On a scale of 1 to 10 rate your stress level:
Do you enjoy the work that you do? *
Are you developing your mental and spiritual capabilities by daily study, meditation and prayer? *
Are you involved in some type of activity in which you are helping others? *
10. Open Air
Do you sleep with your windows closed? *
Are you able to breathe fresh air while you are working? *
Is the building where you work a none-smoking facility? *
11. Daily Exercise
Do you exercise? *
12. Sunlight
Do you often get sunburned? *
Do you visit tanning beds? *
Are you afraid of getting skin cancer? *
13. Proper Rest
Do you snack just before bedtime? *
Do you wake up during the night and snack? *
Do you have trouble sleeping? *
14. Lots of Water
Do you drink any of the following beverages?
15. Always Temperate
Do you currently ingest caffeine in any form? *
Have you ingested caffeine in the past? *
Do you currently smoke tobacco? *
Do you currently chew tobacco? *
Have you used tobacco in the past? *
Do you drink alcohol? *
Have you drank alcohol in the past? *
16. Nutrition
Do you overeat? *
Do you feel stuffed after your meals? *
Do you eat between meals? *
Do you drink with your meals? *
Do you wear removable dentures or plates? *
Do you eat fast? *
Do you have set meal times? *
Are you following any special diet? *
Do you eat animal products? *
Do you eat dairy products? *
What kind of dairy products *
Do you eat desserts, candy or other sweets regularly? *
17. Agreement
Signature:Sign here if you have honestly answered all Consultation questions within this form to the best of your ability.
Sign with your mouse, finger or stylus.
18. Payment
What would you like to pay for at this time? **Prices include a 3% credit card processing fee.

Questions? Call (606) 448-3048 or email info@redriverwellness.org.