Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of birth
*
MM
DD
YYYY
Occupation
*
OHIP #
Primary health concerns
*
Other health/relational/emotional concerns *
*
Other health/mental/relationship concerns
Injuries or physical limitations
Medical history
*
Past diagnoses and health concerns
Medications and supplements
*
Do you consent for our team to obtain a medication list from your pharmacy? If yes, please indicate pharmacy name and phone number
Please share any health goals you may have
*
May include nutrition, exercise, mental health, relational or spiritual. If none, put "None"
Dietary pattern
*
Omnivore
Semi-vegetarian
Mediterranean
Flexitarian
Lacto-ovo vegetarian
Vegan
Paleo
Keto
Other
List any food allergies
List any food sensitivities
Any others allergies or sensitivities? (e.g. drugs, environment etc)
Do you smoke or vape?
*
No
Yes
Do you drink coffee or other caffeinated drinks?
*
Yes
No
Do you drink alcohol?
*
No
Yes
Sleep concerns
*
Meals per day
*
1
2
3
4
5 or more
Snacks per day
*
0
1
2
3
4
5 or more
How many days a week do you exercise?
*
0
1
2
3
4
5
6
7
What kinds of exercise do you do?
*
I understand that reservations are not final until the full amount is paid. You will be contacted via email after your application has been reviewed.
*
I undersand that a basic level of mobility and cognitive ability is required to get the most out of this retreat experience
*
I understand that this retreat does not function as a nursing home, long-term care facility, psychiatric or substance abuse rehab or treatment centre for Covid-19
*
I understand that photos and videos will be taken during the public or group components of the program (e.g. health talks, meals, classes etc). Photos and videos will NOT be taken during therapies, counselling, consults and other private aspects of the program. I understand and accept that photos/videos taken may be used on websites, social media, presentations and other communication channels/media of Paradise Fields and program partners.
*
Is there anything else you would like to share about your interest in One Week In Paradise?
How did you hear about One Week In Paradise?
*
Google
Facebook
Twitter
Instagram
Other social media
Email
Website
Healthcare provider referral
Previous program guest
Poster
Word of mouth
Other