AN IMPORTANT STEP IN YOUR PREPARATION

Taking time to fill out this form truthfully will help in providing the greatest possible experience for you, making it possible to accommodate any special needs or requirements you may have.

Name

First Name

Last Name

Email Address

Postal Address

Please include Country and ZIP / Postal Code

Do you suffer (or have you in the past suffered) any long term health conditions?

Either physical or mental, and please indicate the timespan that you have dealt with the condition(s).

Other than conditions declared above, are you currently healthy?

If no, please state the nature of the condition you are suffering and the severity.

Are you currently taking any prescribed medications?

If so, please make clear which conditions the drugs have been prescribed for and dosage.

Do you use any recreational drugs or self-medicate?

Please indicate approximate use and which drug(s) e.g. Alcohol, Cannabis, Nicotine, Painkillers etc.

Do you have any allergies?

Please indicate the severity of the allergy and the substance.

Are you currently pregnant or trying to get pregnant?

Yes

What is your profession and how much time does it take from each day?

Include time taken travelling to and from work, plus any work you might do at home.

Please provide a short description of what you drink on an average day

Please include approximate quantity of each beverage.

How many meals do you eat a day?

Total occasions; include 'snacks' as meals.

Please choose the option you feel best describes your diet:

If you are unsure, be modest in your response.

Please provide a short description of your night time routine on an average day

Include at least 1hr before bed, what time you usually fall asleep and when you wake up in the morning.

Please provide details of any physical exercise you get in an average week

Include any regular walking you may have to do, or physical exertion as part of your job.

Please choose the option you feel best describes your relationship with meditation

If you unsure, please be modest in your response.

Anything else you'd like to add before we start?

Please include any useful information not covered above.

I hereby declare to have filled out this form truthfully

Please check the details of your answers carefully.

Yes

While you're waiting for a reply, why not check out some free health tips and read about other success stories in my journal?

Health Declaration

AN IMPORTANT STEP IN YOUR PREPARATION