HEALTH QUESTIONNAIRE FOR PARTICIPANTS OF THE HEART OF FIRE RETREAT

Please complete this questionnaire with truthful and detailed information. All data will be treated with strict confidentiality.

PERSONAL INFORMATION

First Name *

Last Name *

Age *

Email *

Phone *

Gender *

Male

Female

Other

Emergency Contact (Name and Phone Number): *

MEDICAL HISTORY

Do you have any chronic illnesses? (e.g., diabetes, hypertension, asthma)

Yes

Do you have any diagnosed medical conditions? (e.g., hypertension, diabetes, epilepsy, asthma, etc.) If yes, please specify: *

Yes

If Yes Please Specify:

Do you take any medications regularly? If yes, please specify: *

Yes

If Yes Please Specify:

Have you undergone any surgeries in the last 5 years? If yes, please specify: *

Yes

If Yes Please Specify:

Do you suffer from or have you suffered from any emotional or mental disorders? (e.g., anxiety, depression, panic attacks) *

Yes

HABITS AND PHYSICAL CONDITION

Do you engage in regular physical activity? *

Yes

How often you engage in regular physical activity

Do you have any special dietary requirements? (e.g., vegetarian, vegan, gluten-free)

Yes

If yes please specify

Do you have any physical restrictions or limitations we should be aware of? *

Yes

If yes please specify physical restrictions or limitation you have

OTHER CONSIDERATIONS

Are you pregnant or suspect you may be? *

Yes

Is there any other relevant health information we should know to ensure your safety and well-being during the retreat?

DECLARATION AND CONSENT

I declare that the information provided in this questionnaire is truthful and complete. I understand that participating in the holistic retreat involves physical activities and practices that may require effort and that it is my responsibility to inform about any health conditions that could affect my experience. Furthermore, I release the organizers from any liability in case of failure to disclose pre-existing medical conditions.

Date: *

Name of referral