BEACON OF HOPE REJUVENATION LIFESTYLE CENTER 3534

BEACON OF HOPE
REJUVENATION LIFESTYLE CENTER
3534 Route 82
Millbrook, NY 12545
(917) 658-4886 (845) 677-3093 (845) 344-7434
Dear Friend:
We here at Beacon of Hope Rejuvenation Lifestyle Center would like to thank you for choosing our Program and realizing
the need to take control of your health. Our program is designed to help you better yourself as a whole person. It is our
desire to teach you the cause of disease, its prevention, and its cure. Education is the key to good health, and our Cleansing
Program is designed to provide you with a broader awareness of what constitutes good health. So, sit back and enjoy learning
about your health !
What you need to bring is warm, comfortable, loose clothing for your stay and other items listed on the enclosed checklist.
Upon returning this Application, Questionnaire and Disclaimer, it is important that you include a deposit of 1/3 of
the total fee. We cannot guarantee any reservation without a deposit. Deposits are not refundable but can be
rescheduled within a two month period. The remainder of your balance must be paid upon arrival. Please make
checks payable to Jerry Jamel. There is a $28 charge for "returned" checks.
If you have any questions or concerns, please feel free to call us at any of the numbers listed above, and if we are
not in, we will certainly return your call.
APPLICATION
Please print clearly
Home Tel. No.:- - - - - - - - - - - - - Cellphone: _ _ _ _ _ _ _ _ _ _ __
Arriv a1 Date:- - - - - - - - - - - - - - Approx. time of arrival:- - - - - How Arriving:
other:- - - - - -car
bus
train _ _.plane
Any pick ups/drop offs are an extra fee and is to be paid to the driver at the time of transport. Fees
are roundtrip :, Airports: Stewart: $90. LaGuardia: $ 145. Kennedy: $ 150. Albany: $137.
White Plains: $1 15. Plus tolls.
Call ahead for other pick up areas. *Metro North Train Stations: $25 .00 Hudson Line: Take Metro
North to last stop - Poughkeepsie. OR - Harlem Line: To Dover Plains or Tenmile River
Greyhound Bus: Call 1-800-23 1-2222 or o n line to www.greyhound.com. Destination : Poughkeepsie, NY
Amount of Deposit Enclosed: $_ _ _ __
Make checks payable to Jerry Jamel.
Check#- - - MO#- - - -- - - - -
If you anticipate any changes or cancellation with your reservation, please notify us two weeks in
advance. "No-shows" are non-refundable. Thank you for your consideration.
Return this sheet with your deposit
Beacon of Hope Welcome letter.pp! rev. 1216/2014
Welcome /
"The doctor of the future will give no medicine but will interest his patients in the care
of the human body, in diet. and in cause and prevention of disease"
Bienvenido
"El medico del futuro no dara medicamentos, pero sera de interes sus pacientes e n el cuidado
del cuerpo humano, en la dieta, yen la causa y a la prevenci6n de la enfermedad"
[~
CLIENT QUESTIONNAIRE
Client Information /
Today' s Date:__________________ _
1nformacl6n del Cliente
Name: _ _ _ __ __ _ _ _ _ _ _ _ _ _ _ _ __
Home Telephone: _ _ _ _ _ _ _ _ _ _ __
(Nombre)
(telefono)
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Street address, apt. II I direccian - ca/le y apartamenta)
(city, state, zip code I cuidad I est ado, zona postal)
Sex I
sexo :
Height I
M ale I
Hombre
_
J Female I
altura:._ _ _ _ _ _ _ __
Weight
Birthdate I
Mujer
I peso: _ _ _ _ _ _ _ _ __
Cellphone:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
St atus:
Estado civil:
Married
Casada
Single
Soltera
Widowed
Viuda
Age/ edad: _ _ _ _ _ _ _ _ __
Email: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Divorced
Divorciado
Symptoms - Reasons for Your Visit I
Reasons for your visit I
fecha de nacimiento: _ _ _ _ _ _ _ _ _ __
Separated
Other_ _ _ _ _ _ _ _ __
Separad os
Otro - - - - - - - -
Sintomas - Razones de su vislta
Razo nes por su visita: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Wh en did you first notice t he symptoms/ lCuando not6 por prlmera vez los sintomas?:_ _ _ _ _ __
Is the Condition getting progressively worse I l
Where specifically is the problems(s) located I l
Es la condici6n cada vez peo r? _ _yes/ si
_ _ _ __
__no
Do nde es especfficamente lo s problemas(s) ubicado / loca li zado?:
Refer to the following page for various health issues.
Please check what may apply to you either currently or in the past.
Vaya a la paglna siguiente para diversos problemas de sa lud.
Por favor, indique lo que se apllca a usted en la actualidad o en el pasado.
Page 1 of 4 I PAglna 1 de 4
!J EA L!JJJ!S'.rn.R\'.
Chc<.:k only
thll&C
conditions thut you cu1Tcn1ly have or had in !he past (pAgc !
E11glish}
~~ ~ ~
<?.'b q_'-q;Oi Problem
• Problem
Problem
Problem
Heartburn I GERD
Abs(1nt·min<led
Aciw
lndig0fition
lnflnmmatory
Aid8 I HIV
W1l12L
__llim:cl_!);""'
Hcmt Pounds HHnl
'l'uberculosir;
Hemorrhoids
Ve11crClt1l lnfcct.iom;
Hernia
Wake Up 'l'ii·cd
Weir,hl problem
Alcoholimn
Luct,01,m lnt.oleruncc
High Blood Pt·ei<Stu•c
Allorgice
Lower Bowel Gas I
J:'bt.nlnnce
H(Jt. Moi:it. of Urn time
A\11,lwimer's Digense
Ulcers
lnfel'tilit.y problemfl
A1wmia
R11domctrit1sis
lnsomi;ia
Appendicitis
Di11,~.incm1
frritab!e befol'c u menl
Al'lhdiis c>1' RA
Eat when Depressed
Ast.hma
gat. when Nei·vous
lt<.:hing of the Nairn
Aul.ism
Eat !.o Hcliof Fat.iguu
Kidnoy Stones
Bad{11chm~
Ec~t!ma
Lighl·hendndnnss
]fad Brcat:h
EmphyBerna
Low Blood Pl'osaui•e
Ble<idii\g (whol'o)
gxccifisivc l"oni·
Lt1mbago
Excru-isivn H11nger
Menstnw.tion, heavy
Chei-;t Paini:-
Exce1;sivo Wol'l'y
Mcirntrtu<tion, skip
ChilJg /Cold Skin
Eye Pl'oblcms
l'vl<?:ntal Disorder
Cho]cr;tcrol, hiRh
Cnt.ai-aels
Motion SidtnCJsB
Cold Hunds/Fcct.
Glaucom11
Nauaen
Conslipntiou
Blindnc1rn
Ncl'V()l!B DlBol'dr!'r
Itching ofthe
Ann,/ll< ''""'
C11nctit
(typo)
Cravings
Faint wlwtt hun1p·y
Night BlindnesR
Cyi;ts
Fatigue (tired)
Obesity
Deprm;slon
Feel
Diabl\tcs
FibroidR I J<'ibror>ik
Difficulty lfrcathing
Di1>m·de1·1>
!~n!quent
Co!dR
Frequent Kidne.v
Painful buw0)
ont
Pant.:rea.titi1>
PnrkinHon'll DiHcm:ie
PoliomyclitiR
P1'0iitatc tl'oublu
Coliti1:1
'""'
FrGquenl u1·in11lion
Ct'oh11's Diacac
Gnllstom~a
Hhoumutic P(Nci·
Digustion t.oo fuat
Hay Fever
Sexunl issues
Divurticulitis I
Head11che1S I migi·ainoB
Sinusitis
lJC'art Di8easo
Skin Prob!nnrn
(lf>ifi
Gulh:tonllfl
G11stritii>
Ulut..en lnto!eni.nce
ll>H wL
H. Pylol'i
Your name·
if hungry
Foul smelHni.bowO!··
lmilll!!n!W.L
Diarrhea
Dif."((l!:!t.iW!
shi~ky
Ht!spit•atot·y pt•oblmns
Angin1J.
Sluggish foelini;;
Athr1rorwlo1·0Bifl
Sti•oaH
Cormrnry Artery
});,.,,
Swollon Oland:;
'
Health history revised 7 1114
Taking med ications? / lEsta tomando medicamentos?
no
_ yes/ si
If yes, the name, dosage and frequency / Si la respuesta es sf, el nombre, dosls v frecuencia
Name of Drug/
""'f:orWh~Pr:bi~~(~)f ·:T P1ra qui problema(5)?.::s• • _•• ·
Nombr•
del "rmaco
.,
___
~
~ ·• : :
List any Vi tamins, Minerals, Herbs, Supplements you are taking on the next page.
Lista de las vitaminas, minerales, hierbas y suplementos que usted esta tomando en lo pagina siguiente.
Eating Habits: (example: eating between meals, eat late, skip meals):
Los habitos alimentarios: (por ejemplo: comer entre comidas, comer tarde, saltarse las comidas):
Drinking Habits: (example: drink w ith your mea ls; type of drinks: soda, liquor, juices, water) :
Habitos de Consumo: (ejemplo: beber con las comidas; el tlpo de bebldas: soda, licores, Jugos, agua):
Family Medica l History
I
Historia medica familiar:
·J
Have you ever tried alt ernative medicines (exa mple - chiropractor, naturopathic, et c.)
_ no _ yes.
If yes, please list and for what problem.
l Ha lntentado alguna vez medicinas alternativas (por ejemplo, quiropractico, natur opathic, etc. )
es si, por favor lista y para que problem a.
_
No
si .
SI la respuesta
List any surgeries or procedures you had and wh en it wa s done .
Lista de las cirugias o procedimientos que tenia y cuando se hizo.
List any Vitamins, Minerals, Herbs, Supplements you are toking
--
Listo de las vitaminas, mineroles, hierbos y suplementos que usted est6 tomondo
Name of Vitamin, etc. /
Nombre de la vltamlna, etc.
Frequency
Frecuencla
Are you currently under a doctor's care?
lEsta bajo los cuidados de un medico? _
No _
Si.
I
For What Problem(s)?
Para qull problema(5)?
_ No _
Yes. If yes, for what condition(s)?
Si la re spucst a es sf, para que condlclon(es)7
Please provide the name and te leph one of a person to contact in case of emergency.
Proporcione el nombre y telefono de la per sona con la que contactar en ca so de emergencia.
Return this entire client health questionnaire
with your deposit
VollH!r todo rstr cumlonarlo dr salud con su drp6slto
Beacon of Hope\ CUent Questionnaire New and Revised 1/14/14 tn1llsh.ppt
Page 4 of 4 I Pflgina 4 de 4
Checklist for Your Stay
La lista de verificaci6n para su visita
-v
Personal
Loose clothing - enough for the length of your stay
Pants
Shirts I blouses
Socks
Sweater
Sneakers or comfortable walking shoes
change of under clothes
Bathing suit (for hydrotherapy - if applicable)
Robe
Slippers
Shower cap
Pajamas
Toothbrush & toothpaste
Hair brush I comb
Shampoo
Misc.
notebook for notes
pen or pencil
Bible
Favorite reading material
Prescription glasses
--Sunglasses
--Your medications
•Your medical supplies (glucose meter, strips,
adult diapers and pads, cholesterol meter/strips, etc.)
Vitamins/supplements/herbs
Current medical reports
(Spanish)
Ropa Af/oje/floja - suficiente para el tiempo de su estancia
pantalones
Las camisas!blusas
Ca/cetines I medias
Sueter
Zapatas c6modo para andar
el cambio de bajo ropa
El traje de bano (para la hidroterapia · si aplicable)
Bata
Zapatillas I chancletas
Garro de bano
Pijama
El cep1/lo de dientes & la pasta dentifnca
El cepillo def pelo I peina (peinilla)
Champu
libro para notas
pluma o el lapiz
Biblia
Material favorito para leer
Gafas de prescripci6n
Gafas de sol
Sus medicinas
Sus suministros medicos (metro de g/ucosa, las tiras,
panales de adulto y a/mohadil/as, metro!tiras de co/estero/,
Las vitaminas!suplementalhierbas
Reportes medicos actuates
You will be walking & possibly sweating, so bring changes of clothing
Bring appropriate clothing based on time of year (summer, winter, etc.)
Usted estara andando & sudando posiblemente, asi que trae cambios de ropa.
Traen ropa apropiada basada en la epoca def ano (el verano, el invierno, etc.)
Linens (towels and bedding) will be supplied by us
Linos (foal/as y ropa de cama) sera suministrado par nosotros
• = There is an extra charge if our supplies are used
•=Hay un recargo si nuestros suministros son utilizados
Pets are not allowed.
Nose admiten animates
Please do not bring your children unless they are going through the program.
Por favor haga arreg/os para sus nifJos mientras usted esta pasando por fa programa.
Personal \Checklist For Your Stay.xis
l'CV. 10/20/14
elc.)
Beacon of Hope R.L.C.
Beacon of Hope Rejuvenation lifestyle Center was founded by
Jerry Jamel and Anna Rodriguez-Jamel
~
l1
..
Beacon of Hope was formed in 200 I with the intention of
educating people as to the health principles which are
built upon biblical understanding of health.
Beacon of Hope reaches out to people that are socially,
physically, spiritually, chronologically, mentally and
economically diverse, in the hope of making them aware
of true health and teaching them to take responsibility for
their own health and lifestyle.
What Dthers Are Saying......
OO®@©©[fi) @fJ [}{)©~
"The entire experience was truly remarkable. The
retreat was a weekend getaway that really provided
me with so much insight that I would recommend
anyone who wants to really feel energized to visit
Beacon of Hope." (Arce/ M.)
lK1®]01JW®uu@UO©[fi)
~~~® ©@[fi)~@([
"Their holistic approach to better health not only
makes you a healthier person, but also educate you
on how to maintain that ever so important habit of
staying healthy. The atmosphere is incredibly
pleasant and private." (Karl G.)
'·Because of the Beacon of Hope Program, we have
decided to go on the vegetarian lifestyle diet and it is
going very well. Anna and Jerry have been a great
and positive influence in our lives." (Jeff & Lois H.)
We believe in dealing with the whole individualphysical, mental, emotional and spiritual. Therefore, our
program and lectures are based on the person as a whole.
We at Beacon of Hope believe in the integration of
biblical counsel, medical research materials and variety
of natural health principles. Using these
methods to
present the health message in a clear, easy-to-understand
manner and in a step-by-step fashion, we believe all who
participate in the program and lectures will benefit from a
healthy lifestyle.
Every day that you invest in
your health, it will pay you back for
years to come !
It is our prayer that you will be richly blessed and that
God will anoint you with the wisdom and power to make
changes in your life in order to achieve optimum health
and to lead others into that healing place.
Price List
Above all else, I want things to go well with you
and for your body to be healthy as your soul.
3John 2