Step 1 of 7 14% Email - Do NOT Change* Best Phone*In case we have a question about your form.AgeHow Did You Hear About The Gate?Please answer the following questions:Why do you wish to attend this Gate?*What does a vital and fulfilled life look like to you?*What do you need to be more sustainable in your life right now?*What energy enriching or constructive factors are currently working for you in your life?*What destructive or energy consuming factors are currently working against you in your life?*Describe your awareness of energy in your body or around you.*Part II. Concerns or symptoms, and how they may influence your lifeDo you have a current or recurring health/life situation or concern?* Yes No Please describe the current or recurring health/life situation or concern.*When did this situation or concern begin?*Have you done anything about this situation or concern, or been given advice or treatment for it?* Yes No What were you told?*What was done?*Did it seem to work?*What was different about you after treatment?*What was different about your condition or symptom after treatment?*Have your concerns changed since treatment?* Please grade the level to which this health concern(s) affects these aspects of your functioning/ quality of life 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect meWork 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Social Life 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Exercise 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Recreation/Play 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Walking 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Eating 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Rest/Sleep 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Sitting 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Love Life 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Concern About Health 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Concern about particular symptom/condition 0 - It does not seem to affect me 1 - It seems to slight affect me 2 - It seems to moderately affect me 3 - It seems to drastically affect me Have any other family members had the same or similar concerns?* Yes No Who was it, and what did he/she do about them?Did it seem to work?*How aware of this are you during the day?* 0 1 2 3 How aware of this are you at night?* 0 1 2 3 Is there any time of day which makes you more/less aware of the above?*Is there an activity during which you totally, or almost totally, forget about the condition, symptom or concern?*Why do you think this has happened, or continues to happen to you?*Do you think this is the sole cause?* Yes No What else is involved?*If this condition or symptom were to go away tomorrow, what would be different about your life?*Are you doing anything differently because of this condition/symptom/concern?*Since the development of this condition/symptom/concern:* Have you changed any habits? Held or touched your body more often or differently? Moaned, cried, or made sounds that you usually do not make (check all that apply)Which best describes your current feeling about yourself and your situation?* I feel helpless, like nothing works This is terrible, really sad: I am scared and hope you can fix it for me I feel stuck and I can't help myself right now I deserve more that what I have been experiencing and would like you to assist me in my healing (check all that apply) Part llI: Overall WellbeingHow do you grade your physical health?* Excellent Good Fair Poor Generally my physical health is:* Getting better Getting worse How do you grade your emotional/mental health?* Excellent Good Fair Poor Generally my emotional/mental health is:* Getting better Getting worse If you consider yourself well, why do you feel well?*If you consider yourself ill, why do you feel ill?*Is there some aspect of your life that very much pleases you, brings you joy, or helps you feel better about yourself?*Are there any particular factors or elements about your life experiences, family, work, recreation, past injuries, genetic, dietary programs, exercises, outlook, etc. that give you an edge or add to your health or wellbeing?*Are there any particular factors or elements about your life experiences, family, work, recreation, past injuries, genetic, dietary programs, exercises, outlook, etc. that you feel impair your opportunity for full glowing health or wellbeing?*Do you have a set exercise, mediation, prayer, nutritional or dietary program? Yes No Please describe the exercise, meditation, prayer, nutritional or dietary programI Exercise Daily Weekly Monthly Never Please describe the exercise routineThe type of diet I usually follow is classified asWhen stressed, describe what you feel and/or do:*Have you consulted a physician or any other health care provider in the past 6 months?* Yes No What was the reason for this visit?*Do you consult with a physician for any other reason than routine evaluations?* Yes No Are you currently, or within the past 60 days, have you have taken medications (prescription or non-prescription)?* Yes No Please list medications (prescription or non-prescription) taken within the past 60 days and purpose of taking them*In the past, have you taken other medications for a period of more than three consecutive months?* Yes No What did you take, and what were the reasons for the medication?*Please list any herbs, nutritional supplements, or natural remedies you take regularly* Part IV: Stress History - PhysicalHave you ever injured your spine?* Yes No Please describe.Please describe.Have you had any spinal X-rays, CT scans, or MRI imaging of your Spine, head, neck, back or hips?* Yes No Please describe.Please describe.Have you broken any bones or significantly sprained any part of the body?* Yes No Please explain.Please explain.Were you ever knocked unconscious?* Yes No Please add comments.Please add comments.Have you ever used crutches, a walker, or cane?* Yes No Please add comments.Please add comments.Have you ever had any impacts, falls, or jolts that you feel specifically may have injured your spine?* Yes No Please add comments.Please add comments.Have you had extensive dental or orthodontal work performed?* Yes No Please add comments.Please add comments.Have you had a work or vehicular accident related injury?* Yes No Please describe.Please describe.Have you served in the Military?* Yes No Were you involved in combat?* Yes No If yes, please advise dates of service and any other useful information to know*Have you ever had your spine or nervous system examined professionally?* Yes No Please describe*During the day I sit.* Yes No During the day I stand.* Yes No During the day I walk.* Yes No During the day I do desk work.* Yes No During the day I do phone work.* Yes No During the day I drive.* Yes No During the day I do mechanical work.* Yes No During the day I do heavy lifting.* Yes No Medical TreatmentHave you ever been hospitalized?* Yes No Please describe with dates.*Have you had any surgeries?* Yes No Please explain including results.*Have you had a spinal tap?* Yes No Have you had a spinal injection?* Yes No Have you had Physiotheraphy?* Yes No Have you had Neck Collar?* Yes No Have you had Spinal Brace?* Yes No Have you had Traction?* Yes No Have you had Heel Lift?* Yes No Have you had X-ray Treatments?* Yes No Have you had Corrective Shoe or Bars on Shoes?* Yes No Have you had Extensive Diagnostic X-Rays?* Yes No Have you had Chemotheraphy?* Yes No Have you had Transfusion?* Yes No Have you had Body part in a cast or immobilized?* Yes No Please provide any additional details concerning these treatments:*Please provide any additional information concerning current and/or past physical stress and trauma.* Part V: Stress History - Mental/Emotional & ChemicalAre you currently under the care of mental health professional?* Yes No Please describe and provide any relevant information.*Have you in the past been under the care of mental health professional?* Yes No Please describe and provide any relevant information.*With each of the following potential stress situations, please check all that apply:Childhood Stress* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)School Stress* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Play or recreational Stress* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Family Stress* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Personal relationships* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Stress of being sick.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Work related stress.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Stress of commuting.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Loss of loved one.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Change in lifestyle.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Change in vocation.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Abuse.* Mid - Past Moderate - Past Extreme - Past Mid - Current Moderate - Current Extreme - Current (check all that apply)Please provide any additional details concerning these stresses.*Please provide any additional information concerning current and/or past Mental/emotional stress and trauma.*General Chemical Stress and TraumaDo you, or did you work with any chemical, fume, dust, powder, or smoke for prolonged periods?* Yes No Please describe including dates*Please provide any additional information concerning current and/or past Chemical stress and trauma.* Part V: Additional InformationPlease describe any personal growth or care modalities regularly used or have used in the past? Please list and include any relevant information.Which is more painful or difficult for you? (choose one)* Your past - Difficulty healing the past or getting rid of something from a past wound, relationship or event Your future - Pain or fear of future events and the impact upon you Which is most often a greater resource of energy, pleasure and/or excitement? (choose one)* The past - Your heritage, family, way of seeing things, doing things and/or organizing life. The future - Going beyond, the far out, creating what has not existed before When you experience pain at its most intense: (choose one)* You experience it from within, as if you are looking out at the world. You experience it as if you are observing your body or pain from outside yourself. When you are most energized and at your peak: (choose one)* You experience from within, as if you are looking out at the world You experience it as if you are observing your body or pain from outside yourself. When you think of improvement in your life that has not happened yet, where in space is it located? (choose one)* Inside of you Outside of you Which of the following describes your current state?* It seems like nothing works. It seems it will never end. I want to get rid of this painful situation. I find the need to find cause. I feel stuck (or blocked) and am being held back. It is time I take my power, life and/or health back. I am willing to peel back my illusions, stories, rules, and beliefs and be with whatever is there to find what is real. I will do whatever it takes as I am so ready. I can feel and sense the next level. I accept what has happened, and am ready for resolution. I realize these patterns once served me, and are now outworn and no longer welcome. I feel grateful for what has happened and will happen. I am very blessed. I realize that we are all connected, and everything is purposely organized. I look for the gift even in the pain. (check all that apply)Which of the following describes your current state? What are the top 3? (number in order 1-2-3)It seems like nothing works. It seems it will never end. 1 2 3 I want to get rid of this painful situation. I find the need to find cause. 1 2 3 I feel stuck (or blocked) and am being held back. 1 2 3 It is time I take my power, life and/or health back. 1 2 3 I am willing to peel back my illusions, stories, rules, and beliefs and be with whatever is there to find what is real. 1 2 3 I will do whatever it takes as I am so ready. I can feel and sense the next level. 1 2 3 I accept what has happened, and am ready for resolution. I realize these patterns once served me, and are now outworn and no longer welcome. 1 2 3 I feel grateful for what has happened and will happen. 1 2 3 I am very blessed. 1 2 3 I realize that we are all connected, and everything is purposely organized. I look for the gift even in the pain. 1 2 3 Have you ever experienced any non-ordinary, consciousness or 'spiritual' awakenings?* Yes No Please Describe*What brings you the most joy, gratitude, well-being or love? What is your bliss?*What are the highest level outcomes you would like to be initiated as a consequence of attending the Transformational Gate? How will that make your life different?*Is there any additional information you wish to provide which you have not yet included in this form?* Statement of Intent: I understand that this is an Educational Seminar, from which I may experience a greater connection with my inner wisdom. One particular spiritual path or model is not stressed as being more valid than others, and different models may be presented during separate programs. I understand that this seminar is not a means of diagnosing or treating any condition, physically, emotionally, mentally, psychologically, or spiritually and that I participate under my own volition and responsibility. I know that this weekend is part of an evolving process, and regular visits to my network practitioner and other frequented healing facilitators are suggested following the program. Although all of the Entrainers are Doctors of Chiropractic, they are offering care as a wellness, awakening and educational tool at this Transformational Gate Program, and not acting in their capacity as chiropractors. Various classes which may include movement, breathing, yoga, toning, meditation, and other forms of internal reeducation and awakening are offered during the Transformational Gate. Any of these types of programs in and of themselves may awaken physical and emotional feelings or memories. It is understood that sometimes healing during the transformational process feels wonderful, or ecstatic, and sometimes it does not feel comfortable at all. It is further understood that if any practice member is currently in the care of a psychologist or therapist, that professional consent has been given by the practitioner to attend this weekend. I grant my practitioner permission to release my personal and clinical information to WISE WORLD SEMINARS for the purpose of assessing me at this program. I understand that portions of the program may be recorded through photo, video and/or audio and I agree to allow Wise World Seminars and its agents to use photos/video/audio taken of me for educational, commercial, marketing, and public relations purposes. Any and all of said reproductions are the exclusive property of Wise World Seminars and Wise World Seminars is the exclusive copyright owner in perpetuity. I shall have no claim, right or interest to any of these reproductions and my signature hereto grants permission to Wise World Seminars to use any of said reproductions in any responsible manner, including, but not limited to: publications, advertisements, web sites, and/or commercial products.I affirm the information on this form is correct and accurate, and I Agree to participate in TRANSFORMATIONAL GATE and/or EUROGATE with the intent described above* I agree Electronic Signature*I understand that by entering my full name below I am providing Wise World Seminars with my electronic signature.Today's Date*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920
