Questionaire - Lisa Bourke

Pre-Retreat

Questionnaire

Please fill out the required fields below.

Step 1 of 14

Name(Required)

Emergency Contact

First Last

Emergency Contact Phone(Required)

Do you have any allergies?

Dietary Requirements(Required)

Have you practiced yoga or qigong before?(Required)

Yes

For how long and what style?(Required)

Do you have numbness/pain in any of the following areas?(Required)

Neck

Shoulders

Elbows

Hands

Wrists

Hips

Lower Back

Upper Back

Knees

Feet

Other

None

Please specify what other areas of numbness/pain

Do you have any current or previous injuries?

Do you have any other health/medical conditions? Please list all.

Are you pregnant? If yes, how many weeks?

Do you have any of the following symptoms at the present time?(Required)

Fatigue

Headaches

Digestive issues

Muscle aches and pain

Skin issues

Brain fog

Weight gain or difficulty losing weight

None

Do you have a pacemaker or an ICD?(Required)

Yes

Do you have an implant, like joint replacements, bone plates/screws?(Required)

Yes

Do you know your Blood Type?(Required)

Unsure

Do you have a laptop that you can bring to the retreat? (For the marketing workshops)(Required)

Yes

Full Payment

Please fill in the required * fields below and one of our team will contact you:

Name(Required)

First Name Last Name

Email(Required)

Phone(Required)

Select Preferred Room(Required)

Company Name(Required)

How did you hear about the retreat?

Privacy Declaration(Required)

I have read and understood the Terms & Conditions

Comments

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