Personal Information Form

Please complete the following form as part of your Vision Quest Booking. It is very important that you provide us with as much details as you can so we can support you on the program.

*All information provided is kept COMPLETELY CONFIDENTIAL and ensures that when your application is approved your Vision Quest will be a safe and rewarding experience.

 
Name *
Name
Could you please write us a paragraph telling us a little about yourself and why you are called to participate in the Vision Quest.
Do you have any current medical conditions that could impact your ability to participate in the Vision Quest Program? Please include full details of any prescription medication or herbal remedies that you are currently taking. Please include the name and contact details of any health professionals you are currently seeing for these conditions.
Do you currently have any sore muscles, aches or general pains in your body? *
Do you currently have a regular exercise activity (walking, running, swimming, yoga etc…)? *
Have you ever had surgery? *
Have you ever been diagnosed with depression and/or seen a Mental Health Professional (counsellor, psychiatrist or psychologist)? *
Do you have or have you ever had any blood sugar problems? *
If you are currently seeing a Health Professional regularly (GP, Mental Health, Naturopath or Specialist in any other field) please detail below what this treatment is for and also provide their current contact details.
Do you have any SERIOUS food allergies that cause medical complications? If yes, please list them, and rate the severity on a scale of 1-10.
Do you carry an EPI-PEN for your food (or other) allergy? *
Do you smoke? *
Have you ever had a drug/alcohol dependency or addiction? *
If yes, please explain.
If yes, please explain:
If YES, please explain
If YES, at what age?
We would love to know more about the unique wisdom you will carry into your Vision Quest. Have you undertaken any other training/courses that you would like to tell us about that might give us a greater understanding of this?
Overall how would you rate your current physical fitness and health?
Overall how would you rate your current mental health and general attitude to life? *