Fathers' 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
ParticipantRevisiting ParticipantSupport Crew
Raising the Masculine HeartInitiating the Masculine HeartHealing the Masculine HeartHealing the Feminine HeartIgniting the Masculine HeartNurturing the Heart of WellnessSacred ConversationsAwakening the Inner Warrior
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
YesNo
Insurance Provider
Policy Number
Insurance Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please explain:
YesNo
If yes, please describe usage:
YesNo
If yes, please describe usage:
YesNo
If yes, please describe usage:
AspirinPanadolOther
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

YesNo
YesNo
YesNo
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
YesNo
YesNo
If yes, please describe briefly:
Personal GrowthRelationship IssuesDepressionFamily IssuesAnxietySpiritual FormationSubstance AbuseSexual Abuse/NeglectIdentity IssuesSuicidal IdeationOther
Have NOT been diagnosed with a mental health condition or chemical imbalanceSchizophreniaDepression/anxietyEating disorderBipolar disorderOther
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
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 confirm that I am not suffering from a mental health condition nor am I psychologicallyunstable, unless I have otherwise stated above and my medical clearance certificate isforthcoming from my specialist.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.I provide my consent for the destruction of my medical history and psychological history documents as deemed appropriate.
agree to provide any updated Medical and Psychological History not later than seven days prior to the first gathering of each calendar year.agree to follow the Code of Conduct and understand that failure to do so may result in appropriate action, which could include removal from part or all of the program.agree that I must respect the confidentiality of all stories, struggles, experiences and other information from or about other participants.
Acknowledgement & Waiver
We the father (the father) and First Name (the son) jointly and severally acknowledge and confirm that:
1. We have enrolled for a retreat/program/workshop with “The Masculine Heart”.
2. The retreat/program/workshop:
  1. may explore issues that are confronting for us or either of us;
  2. may involve activities that we find challenging to participate in;
  3. may challenge us in unexpected ways;
  4. may involve an element of the unknown.
3. We each accept that the above and all other aspects of the programme are a necessary part of the journey we will take in the retreat/program/workshop.
4. We will each participate in the retreat/program/workshop of our 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. We will both 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 we accept full responsibility for our own health, including mental health, and well-being during and arising out of the retreat/program/workshop. The father additionally accepts full responsibility for the health, including mental health, and well-being of the son during and arising out of the retreat/program/workshop.
8. We each participate in the retreat/program/workshop at our own risk.
9. We waive all and any claims of any nature we may have against “The Masculine Heart” and all other participants in the retreat/program/workshop arising out of or in any way connected with our participation in the retreat/program/workshop.
10. We each indemnify and will keep indemnified “The Masculine Heart”, against any claim by any participant in the retreat/program/workshop arising out of any behaviour or action of either of us in the retreat/program/workshop.
11. The father unconditionally and irrevocably indemnifies and will keep indemnified “The Masculine Heart”, against any claim:
  1. by the son arising out of or in any way connected with his participation in the retreat/program/workshop;
  2. by any participant in the retreat/program/workshop arising out of any behaviour or action of the son in the retreat/program/workshop.
12. This Acknowledgment and Waiver forms part of the terms of our contract with “The Masculine Heart” for our attendance at the retreat/program/workshop and is given in consideration for “The Masculine Heart” providing the retreat/program/workshop.
13. The father makes each of the acknowledgements and confirmations above on his own behalf and on behalf of the son.
14. In clauses 9, 10, 11 and 12 above the term “The Masculine Heart” means the registered owner of name “The Masculine Heart” from time to time, Michael Sutton, all contractors, facilitators, agents and employees of “The Masculine Heart” and all contractors, facilitators, agents and employees of Michael Sutton.
15. We have each read and understood the above.
Date

DayMonthYear
Date
Father Signature

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Son Signature

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Medical and Psychosocial History

Medical History

Psychosocial History

Declaration

Acknowledgement & Waiver