Fasting Questionnaire Step 1 of 5 20% General InformationI am interested in..* Consultation Supervised Fast at Tanglewood Supervised Fast via Online Zoom How did you hear about us?*FlierFriend or FamilyInternetMeeting or potluckPrint adRadioLorenConference, fair, festivalAbout Your VisitTell us a bit about your plans to visit usStart Date*At what date would like to start? MM slash DD slash YYYY End Date*At what date would like to finish? MM slash DD slash YYYY How long would you like to stay?*Choose the plan that you think would work best for you1 Week Stay (5 Days Fasting + 2 Days Refeeding)2 Week Stay (11 Days Fasting + 3 Days Refeeding)3 Weeks Stay (16 Days Fasting + 5 Days Refeeding)4 Weeks Stay (21 Days Fasting + 7 Days Refeeding)5 Weeks Stay (26 Days Fasting + 9 Days Refeeding)6 Weeks Stay (30 Days Fasting + 12 Days Refeeding)7 Weeks Stay (35 Days Fasting + 14 Days Refeeding)8 weeks Stay (39 Days Fasting + 17 Days Refeeding)9 weeks (42 Days Fasting + 21 Days Refeeding) Contact InformationName* First Name Last Name Email* Phone (Home): Phone (Cell):* Phone (Work): Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÃ…land Islands Emergency ContactWho should we contact in case of an emergency?Full Name* Relationship Emergency Phone*Emergency E-mail: Personal InformationGender:* Male Female Gender diverse Prefer not to specify Date of birth:* MM slash DD slash YYYY Age:*18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100Height*4 '0 " (122 cm)4 '1 " (124 cm)4 '2 " (127 cm)4 '3 " (129 cm)4 '4 " (132 cm)4 '5 " (134 cm)4 '6 " (137 cm)4 '7 " (139 cm)4 '8 " (142 cm)4 '9 " (144 cm)4 ' 10 " (147 cm)4 ' 11 " (149 cm)5 '0 " (152 cm)5 '1 " (154 cm)5 '2 " (157 cm)5 '3 " (160 cm)5 '4 " (162 cm)5 '5 " (165 cm)5 '6 " (167 cm)5 '7 " (170 cm)5 '8 " (172 cm)5 '9 " (175 cm)5 ' 10 " (177 cm)5 ' 11 " (180 cm)6 '0 " (182 cm)6 '1 " (185 cm)6 '2 " (187 cm)6 '3 " (190 cm)6 '4 " (193 cm)6 '5 " (195 cm)6 '6 " (198 cm)6 '7 " (200 cm)6 '8 " (203 cm)Weight*Please specify kg or lb Marital Status:*SingleSeparatedDivorcedMarriedNo. of Children*012345678910Occupation* Health and Medical HistoryWhat is your current diet?*Present Health Problem:*How long has this been a problem?Surgeries Type(s):Surgeries Date(s): List Complications:Recent Hospitalizations:Present Medications/Hormone Treatments/Supplements:Allergies:Are you pregnant, or think you might be?* Yes No Issues or IllnessesCheck any Present Issues and any Important Previous Illnesses: Anemia/blood disease Hemorrhoids Sinus/nose problem Arthritis Hepatitis Shortness of breath Asthma Hernia Skin problem Back or neck problem High blood pressure Sleep problem Blood in stool High cholesterol Stomach problem Bruise easily HIV/Aids Swollen glands/lumps Cancer Hypoglycemia Swollen joints Chicken pox Intestinal problem Throat problem Chronic cough Jaundice Thyroid disease Clot in veins Kidney problem Tuberculosis Colitis Lipo-suction Tumor, Cyst Constipation Measles Ulcer Depression Migraine headaches Varicose veins Diabetes Mononucleosis Veneral disease Diarrhea Mumps Vision problem Dizziness, fainting Muscle cramps Nervousness Epilepsy Obesity Pain in chest Excessive worry Palpitations Phlebitis Eye trouble Pneumonia Pregnant (currently) Fatigue Psychiatric problem Pseudoatrophy Frequent anxiety Rheumatic fever Scar problems Gain/loss of weight Sensitive skin Gall stones Gall bladder problems Gas or bloating Gum or tooth problem Headache Heart problem Snoring WomenCheck any Present Issues and any Important Previous Illnesses: Birth control pills Breast problem Excessive flow Irregular periods Pregnancy problems Vagina/uterus problem MenCheck any Present Issues and any Important Previous Illnesses: Prostate problem Testicle problem Please explain any that you checked above:Have you been diagnosed with any emotional or psychological disorders?* Yes No Have you been hospitalized for a mental disorder?* Yes No Please tell us about the treatment you received including what kind of medicaitons you've taken and for how long* Health Habits & Fasting HistoryDo you use tobacco? If so, how often?:* Do you drink alcohol? If so, how much?:* Do you drink coffee? If so, how much?:* How much water do you drink a day?* Do you excercise? If so, how often?:* Have you ever fasted before?* Yes No If yes, was it with water or juice? Water Juice Dry fast Have you ever visited Tanglewood Wellness Center before?* Yes No List other detox program(s):Have you been on a weight loss program(s)?Please use this area to explain in detail the health concerns you have and what you have done for them:By typing my name in this box, I hereby confirm my intent to transfer the personal health-related information above to Tanglewood Wellness Center for the purpose of evaluatiion for a consultation or fasting session.*Please read our Privacy Policy before submitting this form. Δ
