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Application for Huna Holistic Healing Retreats
Patient’s information
Name
*
Name
First Name
First Name
Last Name
Last Name
Date of Birth
*
Gender
*
Male
Female
N/A
Phone Number
*
Email Address
*
Key Details
Mailing Address
*
Mailing Address
House Number and Street Name
House Number and Street Name
City/Town, Province/State, Country
City/Town, Province/State, Country
Currently have Cancer, or in Recovery?
*
I currently have Cancer
I am in recovery/remission from Cancer
Type and Stage of Cancer
*
Medical History
Check all other medical conditions that you’ re currently experiencing:
Allergy/Reactivity
Cardiovascular/Heart Conditions
Diabetes
Ear / Nose / Throat
Autoimmunity
Chronic Infections/Illness
Hypertension
Gastrointestinal/Digestive
Urinary/Reproductive
Liver/Kidneys
Lymphatic/Blood
Movement/Mobility Challenges
Neurological/Cognition/Sensations
Mental Health/Depression/Anxiety
Respiratory/Asthma/Breathing
Epilepsy/Seizures
Weight Gain/Loss
Physical Pain
Post-Surgery
Current or Post-Chemotherapy
Current or Post-Radiation
Other
Other
Are you currently taking any medications?
*
No
Yes
Yes
Do you have any known medical allergies?
*
No
Yes
Yes
Are you currently under medical treatment?
*
No
Yes
Yes
Have you been admitted to hospital or had surgery within the last 6-12 months?
*
No
Yes
Do you use tobacco, cannabis, or alcohol?
*
No
Yes
Yes
Are you experiencing Severe or Debilitating Depression, Anxiety, or Mental Illness?
*
No
Yes
Yes
Do you currently use natural, holistic or alternative methods of healing?
*
Daily
Weekly
Monthly
Occasionally
Never
Retreat Interests
Check all of the Therapies and Programs which interest you about our Holistic Healing Retreats:
*
Organ Detoxification
Parasitic Cleansing
Heavy Metal Cleansing
Liver/Kidney/Bowel Cleansing
Lymphatics Support
Rife/Scalar Therapy
Red Light Therapy
Hydrogen H2 Therapy
Low-Frequency Pulse Therapy
Holistic Learning Workshops
Natural Living Learning Workshops
Spiritual Integration Workshops
Emotional and Trauma Healing
Healthy Organic Nutrition
Deep Relaxation and Peace
Interaction with Other Patients
Herbal Medicine
Nature Immersion
Other
Other
Submit
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