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Toggle Navigation
Home
Our Retreats
Our Retreats
Dates & Prices
Weight Loss Retreat
Sugar Detox Retreat
Healthy Holiday
Stress Re-set Retreat
The Menopause Retreat
Conscious Cook and Tone Retreat
Our Locations
About us
Meet the team
Our Values
FAQs
Press
Blog
Conscious Cooking
Womens Wellness
Wellness Retreat or Bootcamp?
Testimonials
Contact us
Booking Form
Juls
2024-07-24T15:12:56+01:00
Booking Form
Booking Form
Full Booking Form
Step
1
of
4
- Contact Details
0%
Contact Details
Full Name
*
Full Postal Address
*
Mobile Phone Number
*
Home Phone Number
*
Email
*
Date of Birth
*
Weight
*
Height
*
Dress Size
*
Sex - Female / Male
*
Describe your activity level.
*
Retreat date you have booked
*
Medical Questionnaire
Are you currently taking any prescribed medication?
*
Yes
No
Are you registered as a disabled person?
*
Yes
No
Do you have any allergies?
*
Yes
No
Are you a smoker or do you Vape?
*
Yes
No
Are you currently suffering or have you ever suffered from heart trouble
*
Yes
No
Are you currently suffering or have you ever suffered from lung disease
*
Yes
No
Are you currently suffering or have you ever suffered from stomach / bowel trouble
*
Yes
No
Are you currently suffering or have you ever suffered from diabetes / hypoglycaemia
*
Yes
No
Are you currently suffering or have you ever suffered from jaundice / hepatitis
*
Yes
No
Are you currently suffering or have you ever suffered from joint problems
*
Yes
No
Are you currently suffering or have you ever suffered from asthma
*
Yes
No
Are you currently suffering or have you ever suffered from sight / hearing problems
*
Yes
No
Are you currently suffering or have you ever suffered from headaches / migraines
*
Yes
No
Are you currently suffering or have you ever suffered from kidney / bladder disorder
*
Yes
No
Are you currently suffering or have you ever suffered from back / neck problems
*
Yes
No
Are you currently suffering or have you ever suffered from high blood pressure
*
Yes
No
Are you currently suffering or have you ever suffered from depression / anxiety
*
Yes
No
Are you currently suffering or have you ever suffered from hernia / rupture
*
Yes
No
Are you currently suffering or have you ever suffered from epilepsy
*
Yes
No
Are you currently suffering or have you ever suffered from surgical operations
*
Yes
No
Are you currently suffering or have you in the past suffered with any type of eating disorder
*
Yes
No
If you answered yes to any of the above questions please provide details below
*
Nutritional Questionnaire
Are you a Vegetarian?
*
Yes
No
Do you eat fish?
*
Yes
No
Are you vegan?
*
Yes
No
Are you Celiac?
*
Yes
No
Are you gluten intolerant?
*
Yes
No
Are you wheat intolerant?
*
Yes
No
Are you lactose intolerant?
Yes
No
Are you allergic to seeds?
*
Yes
No
Do you have a nut allergy?
*
Yes
No
Do you have any food intolerance or allergies not mentioned?
*
Yes
No
Please provide any further details on any positive answers to any question above or any dislikes that may help us to best meet your dietary requirements
*
PAR-Q & You
For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice before increasing their physical activity level. Common sense is your best guide in answering the following questions. Please read them carefully and answer honestly by selecting either 'Yes' or 'No'.
Has your doctor ever said you have heart trouble?
*
Yes
No
Do you frequently have pains in your heart and chest?
*
Yes
No
Do you often feel faint or have spells of severe dizziness?
*
Yes
No
Has your doctor ever told you your blood pressure was too high?
*
Yes
No
Are you currently taking any prescribed medication?
*
Yes
No
Has your doctor ever told you that you have a bone or joint problem that may be aggravated my exercise?
*
Yes
No
Are you pregnant?
*
Yes
No
Are you over the age of 65 and not accustomed to vigorous exercise?
*
Yes
No
Is there any other good physical reason not mentioned here why you should not follow and activity programme if you wanted to?
*
Yes
No
If you answered Yes to any of the above questions please provide further detail including dates where relevant.
*
You should also talk with your doctor BEFORE you commit to this programme.
Phone
This field is for validation purposes and should be left unchanged.
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