Medical Questionnaire & Program Registration

Note: Kindly fill out this form as completely as possible. Certain questions may seem unrelated to your
condition, but they may play an important role in the diagnostic and treatment. ALL information given is strictly
personal and confidential.

Date: 19 Dec 2022

Participant Information:

Given Name: Zuo Seng

Family Name: Lee

Sex: Male

Date of Birth: (dd/mm/year) 17-Sept-1984

Age: 38

Country of Origin: Malaysia

Email address: [email protected]

Civil Status: Married Divorced Widow Single /

Occupation: Digital Marketing

Contact Number: 0163280917

Religion (if any): Buddist

In case of an emergency:

Name: Lee Shu Rong

Relationship: Sister

Contact Number: +60 17-379 3846

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PERSONAL HEALTH HISTORY

Date of last Medical Exam: before MCO

Child:
Measles
Mumps
Rubella
Polio
Rheumatic
Scarlet Fever
Others (please describe:

Others:
Osteoarthritis
Diabetes
Hypertension
Heart Disease
Asthma
Cancer
Genetic Inherited (explain):
Venereal disease
Allergies
Epilepsy
Trouble with coagulation (Bleeding)
Bipolar
Surgeries (please describe below) :

1. Date: _________ Nature:

2. Date: _________ Nature:
3. Date: _________ Nature:
4. Date: _________ Nature:
5. Date: _________ Nature:
6. Date: _________ Nature:
7. Date: _________ Nature:
8. Date: _________ Nature:
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 How many beverages do you take daily that contains caffeine (coffee, tea, soft
drinks)?

1-2 times

 Has your general health changed over the past year?

tired

 Have you seen a Doctor for a specific or specific issue or problem?

tinnitus

 Have you ever had any serious illnesses or hospitalization? (Explain)

no

 Do you have or ever had cardiovascular problems including heart attack or

stroke?

no

 Do you suffer from hypertension problems?

no

Do you have any dependencies? (Circle selected ones)

• Alcohol
• Cigarettes
• Prescription Drugs
• Recreational Drugs
• Sex
• Relationship
• Work
• Gaming
• Phone

• Do you have any emotional disorders (anxiety, depression, stress? Please

explain

no
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• Are you following any diets: (please explain)?

no

• Have you ever received psychological or psychiatric evaluation: (please explain)?

no

• Do you practice any forms of self-exploration (yoga, meditation, Reiki,

bioenergy, others)? – Please explain:

meditation

• How did you discover us? (please explain)

online google search for info

Medicine:
List all the medications prescribed and purchased over the counter including herbal and any
vitamins that you take regularly during the last 3 months and the dosage and the date last
consumed.

• Prescription drugs (sleeping pills, antidepressants, pain-killers and others):

no
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• Vitamins & Herbal:

no

Allergies:
Are there any medications and/or consumable goods that you have experienced a reaction
with? (describe level of reaction)
no

Accidents and Injuries:

Have you ever had an accident? Please explain injuries and surgery if any:
car accident many years ago, bone fix

Trauma and Abuse:

Have you ever experienced any type of trauma or physical/psychological abuse? Please
explain:
father is strict on my academics, and beat me up multiple times

FAMILY HEALTH HISTORY

• Has anyone in your family ever had hypertension problems? Please explain:
slight hypertension
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• Does anyone in your family suffer from arterial hypotension? Please explain:
no

• Does anyone in your family suffer from Diabetes? Please explain:

my grandmother died of diabetes

• Does anyone in your family have a history of psychological problems? Please

explain:
my mother had depression 5 years ago

• Are your parents still alive?

father is gone, mother still alive

• How was your relationship with them before as a child, teenager & adult?
i am distance with them and only discuss with them whenever bigger

issues in the family

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• How was your relationship with them now:

i am staying with my mother now, but we can hardly talk now

• Do you have any brothers and/or sisters? (if yes, how many and their ages)
staying with sister now in the same house

bother is away staying in China now for work and family

• How was your relationship with them before and now?

i have been always distance since teenager years

• Are there any other medical-related issues you would like to add?
no

• Are you or have you ever taken or experienced drugs? If yes, please specify last date
tried or consumed:
no

Marijuana / Cannabis
Mushrooms
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Alcohol
Amphetamines
Valium
Cocaine
Heroine
Mescaline
Crack
Ketamine
Ecstasy (MDMA)
LSD
Others:

For Women only:

Are you presently pregnant or could possibly be? If yes, you can participate in the
ceremonies however no medecines will be prescribed or administered that could
potentially be damaging to your state.

• Is your menstrual cycle regular?

Yes
No

Describe:

• Are you using or taking any contraceptives? (If yes, please describe)
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Objectives of the Sacred Medicine Retreat:

i am staying with my mother now, but its hard to communicate
• Have you ever experienced Sacred Medicines? If yes, please explain:
no

• Have you studied or been explained in general terms the Sacred Medicines? Is there
is anything more, you’d like to know?
yes, i studied books and listned to some fellow mediattion friend about it

• How did you hear about the Retreat?

i googled it and studied info on youtube

• What are your objectives and goals for participating in this Ancestral Medicine
Retreat?
To get into the subconcious level to face my fears on relationship

and also understand the reason behind of body uneasiness/ low energy

Medical Insurance:
• Do you have any private or government funded medical insurance? If yes, please
describe:
yes
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I hereby understand the importance of providing a complete, accurate and true medical
history in order to allow the people in charge and therapeutic guides to offer the best care
possible.

Signature of the participant:

Name: Lee Zuo Seng

MEDICAL LIABILITY RELEASE – ACKNOWLEDGEMENT OF PERSONAL RESPONSIBILITY

I hereby declare of sound body and mind that I am older than 18 years of age and request
to participate in the Ancestral Medicine Retreat for which I have signed the present
registration, medical questionnaire and authorization. I am equally fully aware of the risks
involved if I have not properly or fully answered any of the questions herewith.
I therefore declare that I have clearly and completely answered the questionnaire regarding
my medical history and that I do not offer any potential problems, known or unknown,
regarding my physical, mental or cardiopulmonary capacity or any other condition that
could stop me from participating or cause any complications during the retreat or
thereafter. This includes the consumption of any drugs or medication I am using and/or
failed to declare.
It is understood that my security and welfare rests entirely upon my own ability to care of
myself during the retreat and to respect the instructions and directives before and after the
retreat regarding my diet requirements and health information. If I am receiving any
treatments, I must consult with my doctor before starting any new activities or healing
program.
I hereby sign this document freely and willingly after carefully reading this document and
fully understand that by signing this document I am aware that my participation in this
retreat could possibly be a risk to myself and recognize that such a risk is fully acceptable.

In addition, I unconditionally waive any or all responsibilities/liabilities for damages and

claims of whatever nature, known or unknown, that could potentially be linked to the
preparation, the implementation and my participation in the said Sacred/Ancestral
Medicine retreat, it’s organizers, practitioners, therapists and staff. This includes, but not
limited to, claims involving financial loss, sickness, heath-related issue, injuries or accidental
death.
I declare having read, fully understood and accept this waiver of responsibility and of any
obligations whilst recognizing that this document has not been modified verbally or written.
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The Participant

Name: Lee Zuo Seng

Passport Number: IC 840917145407

Date: 19 Dec 2022

Signature

Representative for the Ancestral Medicine Retreat

Name:

Date:

Signature