Pre-Retreat Questionnaire.info@thesanctuaryibiza.com+44 (0)207 117 2463Santa Eulalia Del Riu, 07840, Ibiza, Spain Name * First Name Last Name Email * Mobile No. (inc international code) * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Passport Number * Date of Birth * MM DD YYYY Gender * Male Female Height (cms or inches) * Weight (kgs or Ibs) * Occupation * Next of Kin * First Name Last Name Their Contact No. (inc international code) * 1)- Do you suffer from any ongoing health issues, if so please describe below with details of duration and current management? 2)- Are you taking any prescription medications, if so please give details and dosage? T3)- Are you taking any over the counter medications regularly, if so which? 4)- Do you take any supplements/vitamins regularly, if so please give details? 5)- Do you suffer from any allergies, including food allergies & intolerances? 6)- Can you tell us about your day to day life..work/retired/children/animals etc. 7)- Do you take part in any physical activity.. what? /how often? 8)- How many hours sleep do you get a night on average? 9)- Do you have any problems relating to sleep? 10)- How much caffeine do you consume a day? 11)- How much alcohol do you consume a day/week? 12)- Do you smoke? If so what/how much? 13)- Do you use recreational drugs? 14)- Do you manage to spend some time outside everyday? (if so please give details) 15)- Do you practice any yoga/meditation/breath work? 16)- How do you like to relax? 17)- Do you suffer from anxiety/stress? Please give details of causes, effects. 18)- Are there any specific past traumas both physical and emotional that you feel impact your life? 19)- Are you currently aware of any deficiencies/blood abnormalities? 20)- Please give details of any previous surgery? 21)- Have you taken any of the Covid-19 injections? If so which and have you experienced any unwanted side effects since? 22)-Are you currently seeing any doctors/therapists on a regular basis, if so please give details? 23)- Do you have any form of addiction or are you a recovering addict? Please give details. DECLARATION: The information that I have provided is, to the best of my knowledge, both true and accurate. I confirm the declaration is true and accurate Acceptance of Terms and Conditions * I accept and agree to abide by the terms and conditions Thank you for your information, we very much look forward to helping you heal mind, body & soul, naturally.
