Prescreening Questionnaire

Note: Must answer ALL questions.

Name*
First Last
HIV/AIDS?*
- Yes
- No
Hepatitis*
- Yes
- No
Which Type?
Diabetes Type 1*
- Yes
- No
Heart Disease or problems*
- Yes
- No
Cancer*
- Yes
- No
If recovering, then for how long and when was your last chemo/radiation treatment
Chemo/Radiation treatment?*
- Yes
- No
Do you have any mental health problems?*
- Yes
- No
Additional information regarding mental health problems:
Are you presently under a doctor's care?*
- Yes
- No
What are you currently under a doctor's care for?
Lap Band Procedures*
Any "lap band" procedures (or anything like that) to make the stomach smaller?
- Yes
- No
Severe Cardiac Disease*
- Yes
- No
Aneurysm*
- Yes
- No
Severe Anemias*
- Yes
- No
Severe Diverticulosis*
- Yes
- No
GI hemorrhage/perforation*
- Yes
- No
Hemorrhoids*
- Yes
- No
Have your hemorrhoids been active in the last 90 days?*
- Yes
- No
Internal or External?*
- Internal
- External
Anything else I should know about them?
Do you have a history of bloody diarrhea?*
- Yes
- No
Do you have a history of diverticulitis?*
- Yes
- No
Do you have a history of colitis?*
- Yes
- No
Do you have a history of bleeding hemorrhoids?*
- Yes
- No
Do you have a history of ulcerative colitis?*
- Yes
- No
Do you have a history of colon cancer?*
- Yes
- No
Do you have a history of rectal fissures/fistulas/abnormalities?*
- Yes
- No
Do you have a history of any kidney condition?*
- Yes
- No
Crohn's disease*
- Yes
- No
Cirrhosis*
- Yes
- No
Presently pregnant*
- Yes
- No
Abdominal hernia*
- Yes
- No
Recent colon surgery*
- Yes
- No
Renal insufficiency*
- Yes
- No
Are you feeling depressed or stuck in life?*
(Please be as honest as you are able. I am the ONLY one who will ever see this).
- Yes
- No
Please explain any of your answers above
Masks Optional
I recommend that if you are immune compromised you wear a mask however that is up to you. Many people fly in to the retreat from all over the world.
I understand that "colon cleansing" every day is a mandatory part of this Cleanse.*
You have two choices and they are doing the professional colonics with the Colon Therapist and/or doing the self-administered method of colon cleansing. One of either method has to be done EVERY day of the Cleansing Fast Retreat (Monday, Tuesday, Wednesday & Thursday).
You may not do the self-administered method of colon cleansing if you are sharing a room with someone you do not know. It takes up too much time in the restroom from the other person. You will already be saving $600 per person by sharing. I may start charging a one-time fee for the self-administered method. I have read and agree.
- Yes
Have you ever had a colonic?*
- Yes
- No
How did it go?*
Be specific.
Please list everything you are allergic to:*
Be exact and specific. Please say "nothing" if you are not allergic to anything.
Male, Female, Other Identification?*
- Male
- Female
- Other
Age*
Date of birth*
Month
Day
Year
Height*
Weight*
Phone*
What is the best number to reach you?
Email*
Where do you live?*
Are you in the health, nutrition or fitness business?*
- Yes
- No
Occupation
Will you have a car?*
- Yes
- No
What is your Fasting / Cleansing Experience?*
- First Timer
- Some Experience
- Very Experienced
No matter what your experience, first time you are coming to this retreat you agree to make your best effort to come to a minimum of the first and last class of the retreat please. (I do not want anyone to put themselves at risk.) Plus this will make the week as easy as possible for you. Thank you very much!*
- Yes
I understand that I may be asked to leave the premises if I cause a toxic, negative, disruptive or otherwise unhealthy environment in any way to any person participating in, working with/at, or hosting the retreat. I also understand that I may be asked to leave if I do not follow the protocol at the retreat, as I may be putting myself at risk for not doing so. I understand that if any of the above situations arise and I am asked to leave, I will not be entitled to a refund. This is at the sole discretion of the leader.*
- Yes
Where have you gone / what have you done?
Personal note from me to you:

I am very passionate and dedicated to helping you get the very best, most incredible life-changing long-lasting experience in just one week. I LOVE how the guests have their lives literally changed by Friday. I will do everything I can to make it a supportive, loving environment for you. I know exactly how to get you through THIS Cleansing Fast Retreat in the safest way possible. I am there to help you not only as a group however also individually. I have a room onsite so you can come talk to me privately also.

ATTITUDE IS EVERYTHING! All you have to do is get yourself there and let me guide you from there. Simple. LET'S HAVE A HEALTHY GOOD TIME!
Which retreat dates do you want to attend?*
I do my best to keep prices as low as possible without cutting corners. If I were to run the retreat out of my house that would make prices much lower however I much prefer the ambiance of a full-service spa located in a boutique Spa-tel (10 rooms) with the hot natural mineral waters. We are in our own PEACEFUL, PRIVATE bubble here. No outside distractions. There is no restaurant onsite (wafting food smells/temptation). No one cooking, partying, having cocktails, bar-b-queuing or eating in front of you. I only allow fasters doing the program on premises making it a powerful experience. All this makes it much more effective with long-lasting results and LIFE-CHANGING results.
Do you want a private or shared room?**
- Shared
- Private
Do you use a "breathing machine" as in for sleep apnea or some other reason?*
- Yes
- No
Do you snore?*
- Yes
- No
Do you have any insomnia issues?*
- Yes
- No
Do you have any other issues that may bother the other person?
Please explain if needed
Anyone who shares a room needs to be considerate and compromise. For instance, if someone comes and likes the room temp at 70 degrees and the other prefers 80 then the compromise would be 75 degrees. These instances rarely come up however to SAVE the $600 PER PERSON you need to be flexible with the situation. Almost always people wind up being each others new best friends however I just need for you to be mindful. Thanks!
I have read and agree to the shared room disclaimer*
- Yes
Do you want me to find you a roommate to SAVE $600?*
- Yes
- No
How did you hear about me?*
- LA Yoga
- Search Engine
- TV
- Radio
- Magazine
- Newspaper
- Twitter
- Facebook
- Referral
- Other
Who do I have to thank?
Which one?
- Google
- Bing
- Yahoo
- Other
Please name the search engine you used:
Name
This field is for validation purposes and should be left unchanged.

Once you hit submit, please wait for the page to turn and THEN scroll down to make sure you didn’t miss a question. IF you miss even ONE question then this form will not go through. Please always follow up with an e-mail to me (lovelifewithjan@yahoo.com) telling me that you did the prescreening questions so I can let you know if it went through or not. Thanks so much for your patience.

PLEASE DO NOT BOOK/PAY before you hear back from me.

Thank you for your time. After I receive your answers then I will get back to you as soon as I possibly can and then we can proceed. I usually answer within the day. Please also check your spam/bulk folder.

Note: Must answer ALL questions.

Contact Me: