Forest Therapy Health Questionnaire

Date *

Name *

First

Last

Date of Birth: mm/dd/yy *

Primary Care Physician

Primary Care Phone

Emergency Contact Name *

Emergency Contact Relationship *

Emergency Contact Phone *

Does your doctor know you are going to participate in this program? *

Does your emergency contact person know you will participate? *

Do you wear a Medic-Alert Tag or any other marker of a medical problem? *

If yes please describe:

Do you have allergic or anaphylactic reactions to any insults, such as environmental substances, foods, drugs, insect bites or stings? *

If yes, please describe, and let us know if you carry an Epi pen or other fast-acting medication:

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