Which retreat are you on?
Total Mind & Body Transformation June 2023

First Name

Last Name

Email

Date of Birth

Sex
MaleFemale

Occupation

Weight

KgIbs

Height

ft & inchescentimetres

Health Conditions and Concerns
(include diabetes type 1 or 2, or gall bladder if applicable)

What medication are you currently taking?

What supplements are you taking?

Any health markers you want to improve? If you know your level write it down (glucose, blood pressure, cholesterol etc.)

Ideal Weight & when last at your ideal weight?


Do you practice yoga, meditation or stress management techniques?
NoYes

if yes, please specify

If not, would you like to learn?
NoYes

To help us with our retreat food preparation, please feedback your food requirements:

I eat everything
NoYes

(if no, complete table below, if yes skip to next question)
Are you:
Vegan (no eggs, no dairy, no meat or fish)Vegetarian (eat eggs and dairy)Pescatarian (eat fish)Dairy freeGluten free (please state if specifically coeliac)Meat free

Do you have any food allergies or intolerances?

All meals are low GL. All meals have a dairy-free and gluten-free option. We use fish in a few recipes with vegetarian alternatives.

FITNESS

Which best describes you:
Unfit. Would struggle on a hill walk more than 20 mins.Moderately fit. Can hill walk for an hour.Pretty fit. Love a 2 hour walk.

Have you previously fasted? How long for? How did you feel?

What are your health goals, what would you like to achieve?
(Health, weight, fitness)


What are your top 3 reasons for wanting to change now?

Reason 1

Reason 2

Reason 3

What other healthy eating regimes you have tried, if applicable?

What usually gets in the way of your success? What are your barriers?

On a scale of 1(low) to 10 (high) how important is if for you to be:

Healthier
12345678910

Slimmer
12345678910

Fitter
12345678910

Is there anything else you would like us to know?

Please read the following carefully and sign below:

We are not a medical organisation and the information and reports generated by us should not be interpreted as a substitute for a medical consultation. Nothing contained in the programme should be construed as medical advice or diagnosis. It is your responsibility to determine, through obtaining appropriate medical advice, that you are fit and well and that such contents and services are suitable for you. It is not our responsibility to do so. Please seek advice from your doctor if you're in any way concerned about your health, you are very overweight, before commencing any exercise regime, if you have an existing medical condition that could be affected by dieting, if you believe you have an eating disorder, or if you are pregnant or planning a pregnancy. The programme is not intended for those under the age of 18 or over 75 without consent from a parent, doctor or guardian.

I agree with the Terms & Conditions