Sacred Conversations 2026 - Medical and Psychosocial History

Medical and Psychosocial History

This form is confidential.
Please read carefully and complete this form to confirm your attendance.

You will be required to provide specific information such as Doctor's phone number,
your Medicare number and Private Health Insurance details. We suggest you have
this information on hand at the time of completing this form to ensure your enrolment
is completed successfully.
Personal Information

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am:
Select event:
Medical History
Emergency Contact

First NameLast Name
Emergency Contact Relationship
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Doctor's Name

First NameLast Name
Doctor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Name/Location
Medicare Number
Do you have Private Health Insurance?
Insurance Provider
Policy Number
Insurance Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you under a physician's care now?
If yes, please explain:
Have you ever been hospitalised or had a major operation?
If yes, please explain:
Have you ever had a serious head or neck injury?
If yes, please explain:
Are you taking any medications, pills or drugs?
If yes, please explain:
Are you on a special diet?
If yes, please explain:
Do you have any dietary allergies? (eg: Coeliac, nut allergy)
If yes, please explain:
Are there any medical reasons that could prevent you from fasting?
If yes, please explain:
Do you smoke tobacco and/or vape?
If yes, please describe usage:
Do you drink alcohol?
If yes, please describe usage:
Do you use recreational drugs?
If yes, please describe usage:
Are you allergic to any of the following?

Other
If yes to other, please explain:
Due to legal constraints, Masculine Heart is not permitted to administer analgesics (paracetamol, aspirin etc). A letter from the participant's doctor stating that there is no allergy may assist in the case of an emergency.

Do you have, or have you had any of the following?

Rows	Yes	No
Active Hepatitis
Arthritis/Gout
Asthma
Angina
Bleeding Disorder
Breathing Problems
Broken Bones
Cancer
Chest Pain or Pressure
Chronic Cough
Circulation Problems
Diabetes
Difficulty Urinating
Drug Addiction
Eating Disorder
Emotional Problems
Emphysema
Endocrine/Gland Problems
Excessive Thirst
Frequent Dizziness D
Frequent Fainting
Frequent Lung Infections
Headaches
Heart Attack
Heart Pacemaker
Heart Disease (of any kind)
Heart Murmur
Heart Palpitations
Heartburn
Hep A
Hep B or C
High Blood Pressure
HIV or AIDS
Hypoglycaemia
Intestinal Problems
Irregular Heartbeat
Joint Problems
Kidney Problems
Learning Disability
Low Blood Pressure
Medical Equip or Devices
Migraines
Neck or Back Problems
Obesity
Physical Disability
Psychiatric Disorder
Seizure Disorder
Seizure (within last year)
Shortness of Breath
Significant Head Injury
Skin Problems
Stroke
Thyroid Problems
Tuberculosis (TB)
Ulcer
Unexplained Sweating
Unexplained Weight Loss
Vision Impairment

Have you ever had any serious illness not listed above?
Did you answer yes to any of the above items?
Have you ever been hospitalised for any of the above conditions?
If you answered yes to any of the above three questions, please explain below. Include the following:
- What specific symptoms are occurring
- How often symptoms/conditions occur
- How long symptoms/conditions last
- How you care for symptoms/conditions
- How symptoms/conditions restrict your activity
- Date of last occurrence
Provide specific details here:
Psychosocial History
Have you been in counselling with a Physician/Specialist, Psychiatrist, Psychologist or other within the past two years?
Are you currently in counselling/treatment?
If yes, please describe briefly:
Reasons for counselling (check all appropriate responses):

Other
Have you ever been diagnosed as having a mental health condition? eg. schizophrenia, depression/anxiety, personality disorder, eating disorder, etc. Or psychologically unstable due to chemical imbalance? eg. bipolar disorder. If unsure, please check your doctor's confirmation.

Other
If yes, please describe briefly:
How severe, on a scale of 1-10 with 10 being most severe, do you rate your present condition?

1

2

3

4

5

6

7

8

9

10

1 is Mild, 10 is Severe
Declaration
Declaration

I confirm the information provided in my Medical History and Psychosocial History is a complete and accurate statement of the physical and psychological factors that may affect my participation in this Masculine Heart Event. NB: If you are currently under the care of a physician or therapist, you should have already consulted with them about the advisability of your participation. If you are currently, or have been recently under the treatment for any physical or psychological issues, please discuss this with Masculine Heart so that we are better able to support you during this event.I agree to notify Masculine Heart should there be any changes in my health status or in any of the information I have provided. I authorise Masculine Heart to release this information to medical personnel in the event of an emergency. I also authorise Masculine Heart to contact my physician or therapist to clarify any questions about my health. I understand that MasculineHeart reserves the right to refuse participation to any person for medical reasons.
If I am enrolling in the Sacred Conversations Program, I:
Acknowledgement & Waiver
1. I have enrolled for a retreat/program/workshop with "Masculine Heart".
2. The retreat/program/workshop:
  1. may explore issues that are confronting for me;
  2. may involve activities that I find challenging to participate in;
  3. may challenge me in unexpected ways;
  4. may involve an element of the unknown.
3. I accept that the above and all other aspects of the programme are a
  necessary part of the journey I will take in the retreat/program/
  workshop.
4. I participate in the retreat/program/workshop of my own free will and
  volition and accept and embrace the challenges.
5. The retreat/program/workshop is not therapy and is not a substitute for
  psychotherapy or other forms of health care.
6. I will remain free of alcohol, drugs (other than prescription medication)
  or conscious-altering substances for the duration of the workshop
  commencing on registration.
7. It is a necessary part of the journey that I accept full responsibility for
  my own health, including mental health, and well-being during and
  arising out of the retreat/program/workshop.
8. I participate in the retreat/program/workshop at my own risk.
9. I waive all and any claims of any nature I may have against "Masculine
  Heart" and all other participants in the retreat/program/workshop arising
  out of or in any way connected with my participation in the retreat/
  program/workshop.
10. I indemnify and will keep indemnified "Masculine Heart", against any
  claim by any participant in the retreat/program/workshop arising out of
  any behaviour or action of mine in the retreat/program/workshop.
11. This Acknowledgment and Waiver forms part of the terms of my contract
  with "Masculine Heart" for my attendance at the retreat/program/
  workshop and is given in consideration for "Masculine Heart" providing
  the retreat/program/workshop.
12. In clauses 9, 10 and 11 above the term "Masculine Heart" means the
  registered owner of name "Masculine Heart" from time to time, Michael
  Sutton, all contractors, facilitators, agents and employees of "Masculine
  Heart" and all contractors, facilitators, agents and employees of Michael
  Sutton.
13. I have read and understood the above.
Date

DayMonthYear
Date
Signature
Should be Empty:

Medical and Psychosocial History

Medical History

Psychosocial History

Declaration

Acknowledgement & Waiver