Health Intake Form

Please complete our required health intake form as a way for Dr. Cousens to assess if the Whole Person Healing program is a fit for you.

We take your health information privacy seriously and all information is submitted via SSL. 

NOTE: Dr. Cousens does not consult with type 1 diabetics.

Requested Appointment Date*
What is your main reason for consultation?*

Personal Information

* *
State (USA ONLY)
Date of Birth*
* *

Emergency Contact Information


Health Status

Please indicate any condition below that applies to you now or in the past. 

If significant health issues are not disclosed prior to arrival the Tree of Life Association reserves the right to ask a guest to leave without a refund.

Bone or Joint Problems
Bowel Disorder (chron's, colitis, etc.)
Candida Albicans (yeast infection)
Cardiovascular disease, heart attack, or any heart condition
Dizziness; Loss of Balance or Consciousness
Epilepsy or seizure disorder
Hypertension/High blood pressure
Hypoglycemia (Low blood sugar)
Prescription Drugs
Prescription drugs (please list)
Liver Disease (Hepatitis)
Nervous System Disease (MS, Parkinson's)
Are you pregnant or suspect pregnancy?
Urinary Tract Disorder
Weight Loss or Gain
Do you currently have or have you ever been diagnosed with a Communicable Disease? (Check all that apply)*
Do you currently have or have you ever been diagnosed with an Autoimmune/Immune System Disease? (Check all that apply)*

Physical Health

Do you have chest pain during physical activity?*
Have you experienced chest pain in the last month when not doing physical activity?*
Do you have a hearing, vision, or structural condition that limits activity in any way?*
Are you more than 20 lbs UNDER the normal weight charts or under your healthy weight? *

Food Notes

Do you have any food sensitivities? *
Do you currently experience food binges?*
Do you have a history of an eating disorder such as anorexia, bulimia, or compulsive over-eating?*
Do you have a current eating disorder? *

Drug Notes

Are you currently using any of the following?

Choose All That Apply*
If you selected any of the drugs above, please list the daily amount, frequency of use, and type of each one.
Have you had a history of drug or alcohol abuse?*
Are you under current treatment?*


Have you experienced panic attacks or frequent bouts with anxiety?
Have you been in psychotherapy for an issue?*
Have you ever been hospitalized for psychiatric or addiction reasons?*
Medications you are currently taking. If not currently taking, please write N/A.*
Medications you previously took. If you have not previously taken, please write N/A.*


Are you under a physician's care for any reason not noted on this form? If so, please describe.
Is there anything else you would like to share?
By checking the box below, I acknowledge that I have read, understood & agree to all the terms of the above Informed Consent - General Medical and Release Policy.*

Electronic Signature

By my signature below, I acknowledge that I have provided the above information truthfully and have read, understood & agree to all the terms of the above document, medical policy, and release form. 

If you are emailing this back to us, your email to us serves as your signature.

Enter Date*

Send Your Form By Clicking "Submit" Below

This document will be placed in a chart we create for you and used by our clinical nurse and the doctor to help them determine which level of care and attention are required during your retreat program.