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

Name *

Name

First Name

Last Name

Email *

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