Health and Wellness Pre-Consultation – Dekha Dëfrï Retreats

Current Health & Medical History

Please answer the following questions as accurately as possible. This information will help our medical team prepare for your virtual consultation and personalize your retreat experience.

Occupation

Do you currently smoke?

Yes

Have you ever been diagnosed with cancer?

Yes

Please provide additional details

Have you ever been diagnosed with poor circulation, deep vein thrombosis (DVT), or peripheral vascular disease?

Yes

Describe briefly

Are you currently pregnant, or is there any possibility that you may be pregnant?

Yes

Not Applicable

Are you currently menstruating or experiencing any vaginal bleeding?

Yes

Not Applicable

Do you currently have any open wounds, skin infections, rashes, or recent surgical scars in the area to be treated?

Yes

Describe the affected area

Do you have any area of your body where you cannot normally feel heat, cold, or light touch?

Yes

Describe the affected area

Therapy Safety Screening

The following questions relate to conditions that may affect the safety or suitability of specific therapeutic modalities used during your retreat, including heat therapy, cold therapy, electrical stimulation, therapeutic ultrasound, laser therapy, and physical activity.

Do you experience severe hives, pain, or breathing difficulties when exposed to cold temperatures?

Yes

Please provide additional details

Do your fingers or toes become white, blue, or painful when exposed to cold temperatures (Raynaud's disease)?

Yes

Please provide additional details

Have you experienced active bleeding or significant bruising in the area to be treated within the past 48 hours?

Yes

Please describe the affected area

Do you have a pacemaker, implantable cardioverter-defibrillator (ICD), or any other implanted electronic medical device?

Yes

Please specify the device

Have you ever been diagnosed with an irregular heartbeat (arrhythmia) or serious heart disease?

Yes

Please provide additional details

Have you been diagnosed with congestive heart failure (CHF) or kidney failure?

Yes

Please provide additional details

Do you have a history of seizures or epilepsy?

Yes

Please provide additional details

Do you have any metal plates, screws, pins, rods, or artificial joints?

Yes

Please specify the location

Spine, Bone Health, Medications & Additional Information

The following questions help our medical team identify any musculoskeletal conditions, medication-related considerations, allergies, and your personal wellness expectations before your retreat.

If we will be treating your neck or back, have you been diagnosed with severe osteoporosis or spinal instability?

Yes

Please provide additional details

Have you been diagnosed with a spinal disc herniation?

Yes

Please provide additional details

Do you have a history of rheumatoid arthritis?

Yes

Please provide additional details

Do you have an active hiatal hernia or an abdominal aneurysm?

Yes

Please provide additional details

Are you currently taking any medication that makes your skin highly sensitive to light or sunlight (such as certain antibiotics)?

Yes

Please provide additional details

Do you have any known allergies to medications, medical adhesives, latex, or metals (such as copper or zinc)?

Yes

Please list your allergies

Is there anything else you believe we should know before your retreat?

Declaration & Electronic Signature

Please review the declaration below before signing electronically.

I certify that the information provided in this Health & Wellness Pre-Consultation Questionnaire is true, complete, and accurate to the best of my knowledge.

I understand that incomplete or inaccurate information may affect the safety and appropriateness of the therapies and services offered during my participation in the Dekha Dëfrï Holistic Retreat.

By entering my full legal name below, I acknowledge that it constitutes my electronic signature and confirms that I have read, understood, and agreed to this declaration.

Electronic Signature

Signature Date

Electronic Signature Consent

I acknowledge that typing my full legal name constitutes my electronic signature and confirms my agreement to the Health Information Declaration above.

I have read, understood, and agree to the Medical Privacy Notice & Authorization for the Processing of Personal Health Information.