Village Health Guest History Form

This form provides us with the necessary medical history to be considered for acceptance as a Health Guest in the Village Immersion program. If you are approved to be a health guest, you will be notified and given instructions for participating in the Immersion.

Full Legal Name (as on photo ID): *

Email: *

Confirm Email

Occupation *

Address of your current residence: *

Date of Birth: *

Phone Number: *

Biological Sex (XY or XX): *

Male (XY)
Female (XX)

Weight (in pounds): *

Height (in inches): *

Episodes alcohol, Disease

Medical History

Diabetes *

0 - None
1 - Prediabetes
2 - Type 2 diabetes, no medications
3 - Type 2 diabetes, taking medications
4 - Type 1 diabetes

Years You’ve Had Diabetes *

< 1 years
1-2 years
3-4 years
5-7 years
8-10 years
> 10 years

Heart Disease *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Asthma *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

High Blood Pressure *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

High Cholesterol / Triglycerides *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Depression / Anxiety *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Thyroid Disease *

0 - No
1 - Hypothyroidism
2 - Hypothyroidism, taking medications
3 - Hyperthyroidism

Digestive Disease / Problems *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Type of digestive disease or problem (ulcer, gastric bypass, Crohn's, diverticulosis, etc.) *

Cancer *

0 - No
1 - Yes, in remission
2 - Yes, taking medications

Cancer Type *

Chronic Pain *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Pain Location and Severity (1-10 out of 10) *

Arthritis *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Arthritis type *

Osteoporosis / Osteopenia *

0 - No
1 - Osteoporosis
2 - Osteopenia (“pre-osteoporosis”)

Insomnia *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Headaches *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Fatty liver disease (NAFLD) *

0 - No
1 - Yes, no medications
2 - Yes, taking medications

Addictions (medications, tobacco, alcohol, drugs, other) *

0 - No
1 - Yes, to medications
2 - Yes, to other substances

Medication Addictions: *

Substance Addictions: (tobacco, alcohol, illegal drugs, etc.) *

List any other diseases / medical conditions you have, or enter “none”. *

List the names (and dosages) of all medications you have taken during the last 4 weeks, or enter “none”. *

List the names of allergy medications you take, or enter “none”. *

List the names of non-medication allergies you have, or enter “none”. *

ER Episodes in Last Year: *

0 - None
1 - One
2 - > 1 in last year

Epi-pen? *

0 - No
1 - Yes
2 - Yes, but not used in last year

Can you perform activities of daily living (bathing, dressing, toileting)? *

0 - Yes
1 - No

Do you have special needs (vision, hearing, walking)? *

0 - No
1 - Yes

Please describe your special needs: *

Do you use mobility aids (scooter, wheelchair, walker, cane)? *

0 - No
1 - Yes

Please describe your mobility aids: *

How far can you walk without stopping to rest? *

< 1 block
1-2 blocks
3-4 blocks
> 4 blocks (> 1/2 mile)

How many flights of stairs can you climb without stopping to rest? *

< 1 flight
1-2 flights
> 2 flights

Do you wander at night (or day)? *

0 - No
1 - Yes

Please describe your wandering: *

Have you been diagnosed with a psychiatric disorder? (schizophrenia, psychosis, etc.) *

0 - No
1 - Yes

Please describe your psychiatric disorder: *

About Your Commitment

Do you understand that you can be asked to leave the program for safety concerns (your own or others)? *

0 - No
1 - Yes

Do you agree to attend and participate in 95% of the treatment? *

0 - No
1 - Yes

Choose your primary goal or reason for participating in the Immersion Program: *

Improve your health
Get off medications
Change your diet and lifestyle
Learn about lifestyle and health
Lose weight
Improve diabetes
Improve heart disease
Other

Other primary goal: *

Choose your secondary goal or reason for participating in the Immersion Program: *

Improve your health
Get off medications
Change your diet and lifestyle
Learn about lifestyle and health
Lose weight
Improve diabetes
Improve heart disease
Other

Other secondary goal: *

Do you agree to allow your data to be anonymously included in outcomes research? *

0 - No (I do not want you to use my data anonymously)
1 - Yes (I am willing for you to use my data anonymously)

Emergency Contact Information

Please provide someone you trust that we can contact in case of emergency.

Emergency Contact Name *

Phone Number *

Relationship *