All information shared in this questionnaire will be kept entirely confidential.

Name

First Name

Last Name

Date of Birth

Gender

Height (cm)

Weight (kg)

Please list any allergies

Please list any dietary restrictions

Are you pregnant?

Do you have any other medical concerns or conditions that we should know about?

On average, how many hours do you exercise per week?

Do you have a specific health goal at the moment? What would you like to achieve from your Peak Health Retreat?

Optional space to add anything we should know about