Cleansing Fasting Rejuvenating Retreat in Hot Springs
"Rejuvenate With Jan"
Cleansing Fast
PRESCREENING QUESTIONNAIRE

Please answer the following prescreening questions. Everyone needs to be at a certain level of health in order for me to facilitate you though THIS cleanse and for you to reap the full benefits. THIS cleanse is very intense and effective. Don't let that scare you in any way as many people breeze right though it!!

For example, an individual that has gone through chemotherapy within the last 3 years has a very toxic body. The cleanse will release these toxins too quickly and they may become very ill. Other health conditions can cause other complications during the cleanse ranging from mild to severe.

Just because you may answer yes to some of these questions does not mean that you cannot participate. Most people are just fine to do this cleanse. Please be absolutely truthful. Failure to reveal all your health issues could result in your not being able to complete the cleanse.

Please answer yes or no to these questions and if you feel the need to explain then feel free to do so.

Do you presently have or have you ever had any of the following:

  • Aids
  • Hepatitis
  • Diabetes Type I
  • Heart Disease or problems
  • Cancer
  • Severe Cardiac Disease
  • Aneurysm
  • Severe Anemias
  • GI hemorrhage/perforation
  • Severe hemorrhoids
  • Severe diverticulosis
  • Ulcerative colitis
  • Crohn's disease
  • Cirrhosis
  • Presently pregnant
  • Abdominal hernia
  • Recent colon surgery
  • Renal insufficiency
  • Fissures/Fistulas
  • Chemo/radiation treatment

If recovering, then for how long and when was your last chemo treatment?

Radiation treatment?

Do you have any mental health problems?

Are you presently under a Dr's care and if yes, for what?

What is your age and date of birth?

Phone number that you can be reached?

Please list any and everything you are allergic to. Be exact and specific.

Thank you for your time. Please either call or e-mail your answers and I will go over them and get back to you as soon as possible

323-259-8939

lovelifewithjan@yahoo.com

www.RejuvenatewithJan.com

www.TheSpringResortandSpa.com

Bye for now!! XOXO Jan.