Nature's Apprentice - Claire Dunn

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Nature's Apprentice - Claire Dunn

Medical Form - ARCHIVED

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Please complete the medical form below.

Please note that all information will be kept private and confidential.

Personal Details

Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Have you ever done a Vision Quest? *

Yes

No

If yes, how many?

Medical History

Are you under the care of a medical professional for a current condition? *

Yes

No

If yes, please explain.

If yes, have you discussed your participation in this program with him/her?

Yes

No

Are you currently taking any medications? *

Yes

No

If Yes, please list medication and condition

List any allergies (including to medications)? *

Do you have specific dietary requirements?

Are you currently under the care of a mental health professional? *

Yes

No

If yes, please explain.

Thank you!

We acknowledge the Wurundjeri, Taungurung and Gunaikurnai traditional owners on whose lands we gather. We pay our respects to their elders, past, present and emerging and acknowledge that sovereignty was never ceded.

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