Client Medical Information Form

Biidaaban Healing Lodge Client Medical Information Form

Please have this form filled out by your family doctor, and ensure information is forwarded back to Biidaaban Healing Lodge with the rest of your Intake Information.

*Physician Name

*Client Name

*Physician Phone Number

*How long have you been seeing this patient?

*When was the last time they had a complete physical?

*Please describe any communicable diseases that this patient has been exposed to? (Example: TB, Hepatitis, HIV, lice, bedbugs, etc. . . )

*Please describe any physical limitations or conditions that may prevent this patient from participating in an intensive treatment process. (Arthritis, Back Injury, Pregnancy etc)

*Please describe any Psychological conditions that may hinder this patient’s process while in an intensive treatment process?(Mental Illness, Anxiety, Chronic Stress etc)

*Please outline any medical conditions this patient has with respect to allergies, dietary requirements etc. that may affect this client’s treatment progress.

*Please list all medications that this patient is currently prescribed.

The Biidaaban Healing Lodge provides intensive 10 day programs in the area of Sexual Abuse, Grief and Abandonment and Anger Management. We use Experiential Learning and Group Participation to provide individuals with a knowledge base and new skills to enhance or develop healthier attitudes. Individuals attending our programs are required to participate in a Core Treatment Process, which can be physically draining and stressful on a client. Methods to release anger are used, and this can be physically challenging to some individuals.

*Based on the information provided above, are you confident this individual can participate safely in Biidaaban’s program?

Yes, I am totally confident

Yes, I have provided additional recommendations below

*Additional Recommendations:

Signature

Date