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*REQUIRED FIELDS
FASTING:
FULL FAST
PARTIAL
IF PARTIAL WHY?
FULL NAME:
EMAIL:
OUTREACH:
Amsterdam
Barcelona
French Riviera
Paris
Parma
CURRENT MEDICATION:
** ALL medications must be brought in the original container with doctor’s instruction
ACTIVITY RESTRICTIONS:
PHYSICAL HANDICAPS:
ANY LIMITING FEARS:
DIETARY RESTRICTIONS:
FOOD ALLERGIES:
HEALTH HISTORY
check conditions and describe below
ADD / ADHD
Diabetes
Joint or Muscle Pain
ANEMIA
Diarrhea/Constipation
Knee Injury or trouble
Appendicitis
Dislocations
Measles
Asthma
Eating Disorder
Migraine Headache
Back pain or injury
Emotional Behavior
Mononucleosis
Bedwetting
Epilepsy
Motion Sickness
Bleeding Disorder
Fainting or Dizziness
Pneumonia
Blood Pressure
Fractures
Rheumatic Fever
Bronchitis
Ear Infections
Skin Conditions or rashes
Chickenpox
Gall Bladder
Sleepwalking
Colitis
Hay Fever
Sprains or Strains
Concussion/ Head Injury
Heat Stroke
Tuberculosis
Tumor or Growth
Ulcer
Urinary Difficulties
Corrective Lenses (eyes)
Heart Disease
Venereal Disease
Cramps
Hepatitis A,B,or C
Hernias
Cystitis
Dental Appliances
HIV Positive
DETAILS ON ABOVE:
NAME ANY INJURIES, ILLNESS OR DISABILITIES NOT MENTIONED AND THE YEAR OF OCCURRENCE:
MY ARRIVAL IN PARIS
DATE:
TIME:
TRANSPORTATION:
CAR
TRAIN / BUS
PLANE
STATION / AIRLINE:
TRAIN / FLIGHT Nº:
AIRPORT:
TERMINAL:
MY DEPARTURE FROM PARIS
DATE:
TIME:
TRANSPORTATION:
CAR
TRAIN / BUS
PLANE
STATION / AIRLINE:
TRAIN / FLIGHT Nº:
AIRPORT:
TERMINAL:
Send
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