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Guest Information Details Questionnaire
Important – To Be Returned ASAP before Arrival
Confidentiality
Fountainhead Retreat is committed to the health and safety of its guests. As part of these commitments, this Medical History Questionnaire is required to be completed by guests prior to arrival. The completed form will only be seen by certain staff members where necessary and is used to guide us about how to assist you as quickly as possible so please be truthful and accurate. If you are in need of immediate medical attention the below details will be given to the appropriate medical officer.

Name of Guest Who is Attending the program:

Date Of Birth:

Phone:

Email:

Address:
Address
Postal Address:
Postal Address
Emergency Contact Name:

Relationship to Emergency Contact:

Emergency Contact Phone:

Emergency Contact Address:
Emergency Contact Address
Age:

Height (CM):

Weight

Martial Status:

Children:
Yes No
Doctors Name:

Doctors Clinic Name:

Doctors Contact Phone:

Doctors Contact Address:
Doctor Contact Address
Are you seeing any Health Specialists? For what treatment?:

Specialist's Name:

Specialist's Clinic Name:

Specialist's Phone:

Specialist's Address:
Specialist's Contact Address
Occupation:

Any Injuries / Illnesses due from your occupation:

Present Health Concerns:

How Long has this been a problem?:

Allergies:

Are you pregnant or do you think you might be?

Do you have any Phobias/Fears?:

Do you or have you ever had an eating disorder?

How long has this been an issue?

Yes/No Please give details where appropriate
Are you presently on any medication or treatment prescribed by a doctor?

What quantity do you take on a daily basis?

Are You a Smoker? If So Please give details:

Do You Drink Alcohol? if so how many units per week?
(NB 1 unit is 1/2 pint of beer or 1 medium glass of wine)

Do you drink coffee or other caffeine based drinks? if so how much?

Do you exercise? if so how often?

How much water do you drink per day?

Have you ever water or juice fasted?

Have you attended any other retreat programmes?

Have you been on any weight loss programmes?

How committed are you to completing a program?

Are there any areas of your programme you are not currently sure about?

Please describe your nutrition on an average day
Morning:

Mid Morning

Lunch

Mid afternoon

Dinner

After Dinner

Have you ever suffered from any of the following illnesses?
Yes / No. if yes, please give details in provided section beneath:

Cancer:

Heart disease, high blood pressure:

Visual defects/ eye conditions (including colour blindness):

Paralysis or other neurological disorder:

Liver Disorder:

Kidney Problem:

Recurrent headaches, migraine:

Vertigo, giddiness or tinnitus:

Hearing defects/ear conditions:

Asthma, brochitis, tuberculosis or other chest disease:

Chest Pains / breathing problems:

Palpitations:

Pneumonia:

Sinus / Nose Problem:

Throat Problem:

Recurrent backache/ neck ache, arthritis,
rheumatism, Muscle spasms / Cramps:

Easy Bruising:

Eczema, dermatitis, sensitive skin,
other skin conditions:

Diabetes, thyroid or other gland problems:

Kidney or bladder problems:

Peptic ulcer, Diarrhoea, Constitpation,
or other digestive/ intestinal/ bowel disorder:

Blood in Stool:

Haemorrhoids:

Tuberculosis:

Ross River Fever, Glandular Fever,
Swollen glans/ joints

Chicken Pox, Mumps:

Colitis:

Tumour, Cyst:

Depression - Clinical Bipolar, Post Natal, Severe Anxiety,
Excessive Worry, Panic Attacks, Nervousness:

Loss/ Gain of Weight:

Eating Disorders:

High Cholesterole:

Hernia:

Urinary Problems:

Gall Stones / Gall Bladder Problems:

Consistent Gas or Bloating:

Fainting Attacks, Blackouts, epilepsy or fits:

Varicose veins causing trouble:

Clot in veins:

Jaundice:

Any blood disorder, anaemia, High / Low Blood pressure:

AIDS / HIV:

Any impairment of immunity to infection/
Any recurrent infections:

Veneral Disease:

Gum or tooth problems:

Hayfever, allergies to drugs, animals etc:

Sexual Dysfunction:

Prostate, Testicle Problems:

Pregnancy difficulties:

Breast Problems:

Gynaecological Problems:

Birth Control Pills:

Any alcohol or drug related problems or illness:

Any other Medical condition, physical or mental
not mentioned above:(Required Field)

Notes:

General Information

Please use this area below to explain in detail the main concerns you have and wish to address in your program.

What have you previously done or what have you used to try cope, effective or not?

What are your goals for this retreat?

What are your major life goals at the moment?

What are you three best virtues?

What don't you like about you?

What did your parents teach you that you will / did pass to your children?

What is your golden rule?

What are the issues that you think really cause your stress?

Please discuss your sleeping patterns (Time to bed, time up, total hours sleep, quality of sleep):

Please discuss your level of comfort with yourself in regard to:
Success:

Financial Security:

Health:

Spirituality:

Identity:

If your were to die tomorrow, what is your main regret?

If you were to die tomorrow what would be your proudest achievement?

Declaration:
1. I declare that, to the best of my knowledge, the information I have given in correct.
2. I understand that I may be required to attend a medical examination

Name:
Date:
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Terms & Conditions

What to bring
Swimwear, Bathrobe, Raincoat, walking shoes (good tread), Tracksuits - Warm Jacket, Torch, T-shirts, Sun hat/cap, slip on shoes. Due to our onsite water and organic treatment plant, please bring Organic products only. Organic body wash included and other organic products available for purchase upon arrival. The water here is delicious.

Please Do Not Bring
Alcohol, any illicit drugs (only prescription medication), Food, Sweets, Coffee/Tea, Magazines or Newspapers.

If approved by management, walkman / iPods, wallets and Mobile Phones can be brought onsite and left in the safe, or hand in the SIM Card (there is minimal reception and usage is not permitted in main areas). We have a phone for guest use that you can receive calls and make calls to family and friends. However, if they become a distraction, management can request you hand them into the office and you can collect on your departure.
Do You Agree to the following: I Agree

Smoking
For those not ready to QUIT yet there is one designated smoking area next door on the grounds of Platypus lodge. As others however do come to QUIT we are inflexible with our rules in regard to smoking. There is nowhere to smoke at Fountainhead as it is organically certified. There is never any smoking inside any building, or in any area other than the designated area. Any breach of smoking policy will result in you affecting others on their programs so please refrain. This is a condition of booking.
Do You Agree to Not Smoke outside designated areas: I Agree

Alcohol and non-prescription drugs
Only come if you are able to refrain from consumption of Alcohol or non- prescription drugs for the duration of your visit. You must not have consumed your substance for a minimum of 5 days before arrival or you must commit to our 5 day detox offsite before commencing your program. Doctor appointments will be organised and strictly adhered to. Alternatively you having a doctors certificate with you to support your stay with us. Any breach of this policy will result in immediate expulsion with no refund applying. This is a condition of booking.
Do You Agree that You have will not consume Alcohol or non- prescription drugs during your stay:I Agree

Booking Policy
All rates and prices include GST and are firm at the time of booking, otherwise subject to change without notice. It is highly recommended that guests use travel insurance to cover cancellations, medical and other emergencies.

We only accommodate a small number of guests at one time live in and are normally heavily booked so our policies are inflexible in this area. To confirm your booking, payment in full including transfers must be received 21 days before arrival. For cancellations with less than 14 days notice 75% of the full fee is not refundable. For cancellation from 7 days before to completion of your program no refund is possible. Those changing arrival dates with less than 14 days notice will be charged for the nights missed or shorten their program by the same days. So please consider all details before booking or attend a weekend seminar in advance to be sure this type of program is for you. For these programs to have the best chance of providing real long-term help, they must be completed. Often when confronting fears and other issues that tend to come up, there will be an urge to "run away". With our support you can push through this. We are more concerned with you finishing a program than starting one.
Do You Agree to the Booking Policy :I Agree

Transfers
Fly into Sunshine Coast airport if possible, Brisbane if not. We will personally meet and greet you you on arrival. If not possible we will bring you to and from the airport to our door.

If you drive yourself to Fountainhead in your own car, please not that we require you to hand your keys in for the period of your program. No one can leave the property unless agreed with management as we have a Duty of Care.
Do You Agree to hand in your keys if driving yourself? :I Agree

Accommodation
We are not a resort, we are a retreat on a 38 acre organic farm. Our focus and energies are directed to learning and education and change in a natural farm environment. If you are looking for Versace - this may not be for you - we are not 5 star.
We have two accommodation choices and our prices and programs reflect this. These are also based on availability: 1. Standard - The Avocado Cabins - Set in our Organic Avocado orchard right next to the centre - our award winning sustainably designed two bedroom Cabins, own bedroom shared facilities or a cabin for Palladium.
2. Budget Accommodation - Platypus Lodge - 150 meters from the main centre - a two storey converted large farm house that sleeps five (all own bedroom) with shared facilities for the Fountainhead 28 Days Beat the Blues and Change Your Life programs.
Do You Agree to the accommodation terms :I Agree

Guarantees
We can not perform miracles and this educational program does not work for everyone, no matter their good intent so no guarantee can be given. For the program to be given its best chance to work, (and it works for so many as over 4000 have attended since 2002) the following commitments must be made. You must stay for the duration of your program. You must attend the full planned program including scheduled lectures, Life Coaching, Mindfulness and Journey Style Therapy. The success of the program is based on your ability to hear and assimilate this new information and for it to change your current stress causing beliefs. You must be committed to applying the new information you will learn. References are all over the web site, on YouTube and references by phone can be provided. Please discuss any of the above with your Customer Service representative if not certain.

Do You Agree to follow these terms? :I Agree

Duty of Care
Fountainhead Organic employs neither Doctors nor Psychologists. We employ Life Coaches that have been trained in The Fountainhead Method TM. All programs are educational-not therapeutic. The Fountainhead Method TM is simply a philosophy that explains stress and the beliefs behind our reactions to it. We have developed this over the last ten years with the help of over 4000 guests. For more information go to www.28daystobeattheblues.com which introduces the book written by the Founders explaining the method in detail. Guests whom may have had suicidal thoughts over the last twelve months or require 24 hour care must bring their own chaperone or pay to have one provided. If during your visit suicidal thoughts arise, you must immediately notify us so that we may get professional help in this area. Fountainhead Organic provides supervision from 7am to 7pm. At no time are guests allowed off the property, unless supervised by a Retreat Host, during the duration of their retreat. If you are on medication for your illness DO NOT REDUCE OR CEASE TAKING IT until you have completed your program and only then with your medical Doctor's agreement and
supervision.
Do You Agree? :I Agree

Detox Box Use Agreement
The High Tech Health Far Infrared (Detox Box) is an optional included therapy designed to bring energy and wellness back into your
life. Many have used the Detox Box to great personal benefit, however it is not a simple sauna so Fountainhead ask that guests follow
the below rules and precautions before enjoying the experience of the Detox Box.

1. Consult your physician prior to using the Detox Box if any of the following apply, or may apply, to you:

~ If you are pregnant
~ If you have obesity, heart disease
~ If you have low or high blood pressure
~ If you have circulatory system problems
~ If you have diabetes
~ If you use medications

2. Do Not use the Detox Box under the influence of illicit Drugs or Alcohol as this may cause serious health complications.

3. Use only under staff supervision.

4. You must be completely dry when entering the Detox Box and towels must be placed where you sit at all times.

5. Exercise Care when entering and exiting the Detox Box.

6. Do not alter the time or temperature.

7. If at any point you feel ill or unwell during your session in the Detox Box leave and notify a staff member immediately.

8. After the session, immediately have a cold shower to remove toxins sitting on skin.

Do You Agree? : I Agree

I , , hereby state that I have read and understand the above information and agree to all terms and conditions outlined.
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Payment

If paying by credit card please fill in below:

Your Name

Your Email

Invoice Number:

Card Type

Card Number

Expiry Date Format: (MM/YY)

Amount

Are You using a card in someone's name to pay for you program?

IF Yes Please have the card holder fill out the below

Name on Card

I the card holder give permission to use the card disclosed above.
Yes/No

I agree that Fountainhead Organic Retreat have my permission to process my details for the amount listed above.

Or for direct debit:

BANK NAME: BOQ
ACCOUNT NAME: Mentoring Institute
BSB: 124-156
ACCOUNT No: 21 541 880