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Deep Nature Retreat Booking Form

Deep Nature Retreat in Andalusia, Spain

Booking Form

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About You

Name
Date Of Birth
date_range
Passport Number
Passport Expiry
date_range
Home Name / Number
Postcode
Phone
Email

Emergency Contact

Emergency Contact Name
Relationship To You
Emergency Contact Phone
Emergency Contact Email

Physical Activity Readiness Questionnaire (PAR-Q)

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor?
Do you feel pain in your chest when you perform physical activity?
In the past month, have you had chest pain when you were not performing any physical activity?
Do you lose your balance because of dizziness or do you ever lose consciousness?
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
Is your doctor currently prescribing any medication for your blood pressure or for a heart condition?
Do you know of any other reason why you should not engage in physical activity?

If you have answered YES to one or more of the above questions, consult your physician before engaging in physical activity. Tell you physician which questions you answered YES to. After medical evaluation, seek advice from your physician on what type of activity is suitable for your current condition.

General and Medical History

Occupational

What is your current occupation?
Does your occupation require extended periods of sitting?
Does your occupation require repetitive movements?
If Yes, Please Explain
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Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
Does your occupation cause you mental stress?

Recreational

Do you partake in any recreational physical activities (golf, skiing, etc.)?
If Yes, Please Explain
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Do you have any additional hobbies (reading, video games, etc.)?
If Yes, Please Explain
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Medical

Have you ever had any injuries or chronic pain?
If Yes, Please Explain
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Have you ever had any surgeries?
If Yes, Please Explain
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Has a medical doctor ever diagnosed you with a chronic disease, such as heart disease, hypertension, high cholesterol, or diabetes?
If Yes, Please Explain
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Are you currently taking any medication?
If Yes, Please Explain
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Any Other Information
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I agree to the Cancelation & Payment Policy.
Signed Name
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