Application / Intake Form

Waiting List – Distance Healing Journey

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Retreat Guru is the online booking agent for Paititi Distance Healing.

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Contribution

Select a price.

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$500.00 – Full Program (Nutritional Coaching, Dream Exploration, One-on-One Coaching & Energetic Healing)

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$200.00 – A la Carte: Nutritional Coaching Only

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$200.00 – A la Carte: Spiritual Coaching Through Dream Exploration Only

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$100.00 – A la Carte: One Hour One-on-One Transformational CoachingOne-on-One Transformational Coaching Only

Optional Items

Additional Coaching Sessions

$100.00

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Participant Info

First Name *
Last Name *
Email *
Confirm Email *
Phone *
Second Phone
Address *
Address 2
City *
State/Prov. *
Zip/Postal *
Country *
Birth Date *
Gender *
Height *	feet/inches
Weight Today *	Pounds
Number of Children *
Profession *
Emergency Contact Info *	Full Name, relationship, phone #, & email
In which way you would like to work with us? *	I am interested in participating in the Distance Healing Journey with the desire to continue my healing journey at Paititi Institute’s Healing Center in Peru. I would like to be a Distance Healing participant only and do not have intend to participate in Peru at this time.
How did you hear about this program? *

Medical Background

Describe health condition(s) you would like to work on in this program: *
If listed more than one condition above, specify which is your prority to focus on at this time. *	Enter "none" if you have no issues
Date diagnosed *
How were you diagnosed? *
Date of last physical exam: *
What laboratory procedures were performed during this exam: *	stool analysis, blood & urine chemistries, hair analysis, etc.
What was the outcome of these tests? *
Are you currently taken any medications or vitamin supplements (prescription or over-the-counter)? *	If yes, specify name, dosage & duration of use? If no please state this.
Have you stoped taking any medication(s) in the last year? *	share the name of medication, when stopped, & how the transition process went (or is going)
Major hospitalizations, surgeries or injuries: *	list all procedures, complications (if any), outcomes, & dates
Are you exposed to potentially harmful chemicals and/or life threatening activities? *	if yes, please specify (pesticides, radioactivity, solvents, fireman, mining, etc )
Rate the of stress you experience in your life currently on a scale of 1 to 10 *	1 very low low - 10 very high
Identify the major causes of stress: *
List all health problems you have had in the last year: *
Do you have:	Glasses or Corrective Lenses Dentures Hearing Aid Medical Devices/Prosthetics/Implants
Any recent change in your ability to:	See Hear Taste Smell Feel hot or cold sensations Move around
Strong LIKE for any of the following flavors: *	Sour Sweet Spicy/Pungent Bitter Rich/Fatty Salty No Preference
Strong DISLIKE for any of the following flavors: *	Sour Sweet Spicy/Pungent Bitter Rich/Fatty Salty No Dislikes
Do you... *	Prefer warmth (i.e. food, drinks, weather, etc.) Prefer cold (i.e. food, drinks, weather, etc.) No Preference
Is your sleep disturbed at the same time each night? If yes, what time? *
Time of day you feel the most energy or the least symptoms: *	7am - 9am 9am - 11am 11am - 1pm 1pm - 3pm 3pm - 5pm 5pm - 7pm 7pm - 9pm 9pm - 11pm 11pm - 1am 1am - 3am 3am - 5am 5am - 7am I don't notice a pattern
Time of day you feel the worst or your symptoms are aggravated: *	7am - 9am 9am - 11am 11am - 1pm 1pm - 3pm 3pm - 5pm 5pm - 7pm 7pm - 9pm 9pm - 11pm 11pm - 1am 1am - 3am 3am - 5am 5am - 7am I don't notice a pattern
Do you experience any of the general symptoms EVERY DAY (check all that apply):	Debilitating fatigue Shortness of breath Insomnia Nausea Vomiting Bleeding Diarrhea Discharge Headaches Itching/rash Chronic inflammation Constipation Depression Panic attacks Fecal incontinence Dizziness Urinary incontinence Disinterest in sex Low grade fever Disinterest in eating Chronic pain
Personal medical history (check all that apply): *	Allergies/hay fever Alcoholism Alzheimer’s disease Arthritis Asthma Autoimmune disease Blood pressure problems Bronchitis Cancer Chronic Fatigue syndrome Circulatory problems Colitis Dental problems Depression Diabetes Diverticular Disease Drug addiction Ear Problems Eating disorder Elevated cholesterol Emphysema Environmental sensitivities Epilepsy Eye problems Fibromyalgia Food Intolerance Gastroesophageal reflux disease Genetic disorder Glaucoma Gout Heart Disease Infection (chronic) Inflammatory bowel disease Irritable bowel syndrome Kidney or bladder disease Learning disabilities Liver or gallbladder disease Mental illness Mental retardation Migraine headaches Neurological problems Obesity Osteoporosis Paralysis Parkinson’s Pneumonia Seasonal affective disorder Sinus problems Skin problems Stroke Thyroid trouble Tuberculosis Ulcer Urinary tract infection Varicose veins None
Health History of your immediate family (parents & siblings) - check all that apply:	Alcoholism Alzheimer’s disease Arthritis Asthma Cancer Depression Diabetes Drug addiction Eating disorder Genetic disorder Glaucoma Heart Disease Infertility Learning disabilities Mental illness Mental retardation Migraine headaches Neurological problems Obesity Osteoporosis Stroke Suicide Other None

What types of therapy have you tried for your condition past or present? (explain what you did & it’s effectiveness)

Diet Modifications:	provide details on what you did & it’s effectiveness
Fasting:	provide details on what you did & it’s effectiveness
Vitamins/Minerals:	provide details on what you did & it’s effectiveness
Herbs	provide details on what you did & it’s effectiveness
Homeopathy:	provide details on what you did & it’s effectiveness
Chiropractic:	provide details on what you did & it’s effectiveness
Massage Therapy:	provide details on what you did & it’s effectiveness
Traditional Chinese Medicine:	provide details on what you did & it’s effectiveness
Conventional Drugs:	provide details on what you did & it’s effectiveness
Surgery:	provide details on what you did & it’s effectiveness
Other:	provide details on what you did & it’s effectiveness

Men's Health

Please check all that apply (Men):	Benign prostatic hyperplasia (BPH) Prostate Cancer Decreased sex drive Infertility Other
Do you have any other entries to your medical history? If you selected "other" above please explain.

Women's Health

Please check all that apply (Women):	Menstrual irregularities Endometriosis Infertility Fibrocystic breasts Fibroids/ovarian cysts Vaginal infections Decreased sex drive Pelvic inflammatory disease Sexually transmitted disease Other
Age of first period:
Date of last gynecological exam:
Mammogram Results:	Positive Negative Not applicable
PAP Results:	Positive Negative Not applicable
Birth Control (past or present)?	specify start & end dates of all times you have taken birth control, type of birth control & any side effects
Number of children:
Number of Pregnancies:
Have you had:	C-section Surgical menopause Menopause
Date of last menstrual cycle:
Length of cycle (# days):
Any recent changes in normal menstrual flow?	heavier, large clots, scanty, etc

Heath Habits:

Do you use tobbaco?
Cigarettes per day:
Cigarettes per week:
Do you drink alcohol?
Drinks per day:
Drinks per week:
Do you drink caffeine?
Coffee (# 6oz cups per day):
Tea (# 6oz cups per day):
Soda (# 6oz cups per day):
How many days a week do you exercise?
Adverage length of your workouts?
List your form of exercise:	walk, run, job, jump rope, weight lift, swim, yoga, etc

Nutrition & Diet:

Basic Diet:	Mixed food diet (animal & vegetable sources) Vegetarian Vegan Other
Specific food restrictions?	No Dairy No Soy No Corn No Eggs No Wheat No Glutten Only Raw Food No Raw Food Other
Typical daily diet & additional info we should know about yoru diet & restrictions? *	good habits, bad habits, if you listed other above please expain here
Eating Habits:	Skip breakfast One meal/day Two meal/day Small frequent meals Food rotation Often eat on the run Add salt to food
State all allergies (food, medicine, etc).	If none, please state this
Daily servings of fruit:
Daily servings of dark green or deep yellow/orange vegetables:
Daily servings of grains (unprocessed):
Daily servings of beans, peas, legumes:
Daily servings of dairy, eggs:
Daily servings of meat, poultry, fish:

Background & Goals:

Please share a little about your background & inspirations in life *
What do you feel is in the way of your fulfilling your full potential? *
Please share your goals in working with us as a Distance Healing participant (and at our Healing Center in Peru if applicable). What changes would you like to make in your life? *
If there is anything else about you or your condition you would like to share with us please do so here:

Confirm and Submit:

Terms and Conditions *	I understand and accept the terms and conditions as outlined in the client engagement package:Read Client Engagement Package Here This package must be signed an returned after your orientation call.
*	I confirm that I have answered all questions truthfuly and to the best of my ability:
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	Retreat Guru is the online booking agent for Paititi Distance Healing. Charges will appear on your bill as "Retreat Guru"