Health Form - Wild View Retreat

Personal

Name*

First Last

Date of Birth*

Your Age*

Please enter a value between 18 and 75.

Please tell us your age

Your Height*

Please tell us your height. For example, 184cm or 5ft 4inches.

Your Weight*

Please tell us your weight. For example, 65kg or 10.2 stone.

Date of Retreat*

Type of Retreat*

Address*

Street Address Address Line 2 City County Post Code Country

Gender*

Male
Female
Rather not say

Occupation*

Phone Number*

Email*

Emergency contact name and contact information*

Health

Please answer the questions below with as much detail as possible. If you answer YES to any of the questions, please provide further details, where applicable.

Do you have any past or existing health problems?*

Yes
No

Do you have any current or previous issues with you weight?*

Yes
No

Have you suffered from any past or present eating disorders?*

Yes
No

Do you have aches and pains?*

Yes
No

Do you have any problems with your muscles or bones?*

Yes
No

Have you had any previous fractures?*

Yes
No

Do you suffer from osteoarthritis?*

Yes
No

Do you have any heart problems?*

Yes
No

Do you have or ever had high blood pressure?*

Yes
No

Do you have respiratory problems?*

Yes
No

Do you have neurological issues?*

Yes
No

Do you have type 1 or 2 diabetes?*

Yes
No

Do you have any allergies we should be aware of? Including fragrance/essential oils allergies*

Yes
No

Are you pregnant?*

Yes
No

What medications do you currently take?

What supplements do you currently take?

If you have answered YES to any of these questions please provide details here:

Additional

What is your previous experience with yoga/fitness?

Is there anything your instructor should know before you join a class?

How would you rate your fitness levels?

What are you main aims for the retreat?

Is there any specific information you’d like to share with us to aid your enjoyment of the retreat?

Do you have any specific dietary health related requirements? All our juices/smoothies/meals are refined sugar free, gluten free, vegetarian with vegan options. FOR FOOD WEEKS ONLY NOT JUICE WEEKS - Please advise us if you feel you will need separate meals and if so this can be created by the chef there will be an extra fee of €150 per week.

If I have booked a massage, I agree not to cancel within 24 hours notice. I understand that after receiving a massage I might feel some tension or pain in my body afterwards, especially if I have requested a deep tissue massage.*

I agree

As a guest of Wild View Retreat, I hereby agree for this questionnaire to be held confidentially on file by Wild View Retreat for use by Wild View Retreat only, on the impending retreat and any future retreats. I also state that I wish to participate in activities, which may include aerobic exercise, resistance exercise and stretching, such as yoga, pilates, power walks, massage, swimming, guided walks and hikes at my own risk and waive all liability on Wild View Retreat and its staff.*

I agree

If I have answered YES to any of the health related questions I hereby confirm myself fit or have sought my GP’s permission, to participate in the retreat activity outlined on the website. I confirm that I will notify Wild View Retreat of any changes in terms of my health and fitness mentioned in this questionnaire prior to participation on the retreat. I hereby state that I have read, understood and answered honestly the questions above. I understand that my participation in these activities involves the risk of injury and even the possibility of death. Furthermore, I hereby confirm that I am voluntarily engaging in an acceptable level of exercise, which has been recommended to me.*

I agree

I understand that any activity partaken outside of the grounds of Wild View Retreat during my stay, i.e. going for walks alone or with other group members without Wild View Retreat staff present, or renting bicycles that do not belong to Wild View Retreat, I do so at my own risk and waive all liability and responsibility for my health and safety to my own personal risk and not that of Wild View Retreat owners or staff*

I agree

I agree to inform Wild View Retreat if there any reason why you may find a juice detox more challenging than other guests ? Ie physical limitations, addictions, weight issues, mental health concerns.*

I agree

Please elaborate on why you might find a juice detox more challenging (if applicable)

Health Questionnaire and Liability Waiver Form

Personal

Health

Additional