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Signature Form

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Signature Form

Signature FormCary Boulez2020-05-27T10:44:49+01:00

Lose weight safely & sustainably

Signature Retreat Form

Before you complete your registration for the Signature Retreat@Home there is a little bit of form filling to be done. This isn’t just administration but is necessary for us to ensure that we are looking after your health and wellbeing from the outset. It will only a take a few minutes but your answers are really important and may mean that we can better support you during your Retreat@Home

Signature Form

Step 1 of 3

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Name*
First Surname
CONTACT DETAILS
Address*
Street Address Address Line 2 City County Post Code Country
Email*
Phone*
Select Retreat@Home Date you want to attend*
PERSONAL DETAILS
Date of Birth*
MM slash DD slash YYYY
Height (cm or ft&ins)*
Current Weight (St/lb or Kg)*
Sex*
- Female
- Male
Are you a Vegetarian ?*
- Yes
- No
Do you eat Fish?*
- Yes
- No
Are you Vegan?*
- Yes
- No

MEDICAL HISTORY
Are you currently suffering from or have you ever suffered from any of the conditions listed*
- Heart Trouble
- Lung Disease
- Stomach/Bowel Trouble
- Diabetes/Hypoglycaemia
- Jaundice/Hepatitis
- Joint Problems
- Asthma
- Hearing/Sight Problems
- Headaches/Migraines
- Kidney/Bladder Disorder
- Back/Neck Problems
- High Blood Pressure
- Depression/Anxiety
- Hernia or Rupture
- Epilepsy
- Surgical Operations
- None of the above
If you ticked any of the above please provide details
What are your goals for joining Retreat @Home?*
Current Activity level*
Current Diet Habits*
What other Weight Loss plans/Solutions have you tried in the past? (eg WW, Sliming World, Lighter Life, Keto, Juice Diet )*
Tell us why you feel you haven’t achieved your goals up to this point? (e.g Motivation, Health, Confusion, Time etc)*
Are there any challenges to your completing your Retreat @Home?*
What made you apply for Retreat@Home today?*

PAR-Q & You
For most people, physical activity should not pose any problems or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should seek medical advice before increasing their physical activity level.
Common sense if your best guide in answering the following questions. Please read them carefully and answer honestly by placing a X in the appropriate box.
1. Has your doctor ever said you have heart trouble?*
2. Do you frequently have pains in your heart and chest?*
3. Do you often feel faint or have spells of severe dizziness?*
4. Has your doctor ever told you your blood pressure was too high?*
5. Are you currently taking any prescribed medication?*
6. Has your doctor ever told you that you have a bone or joint problem that may be aggravated my exercise?*
7. Are you pregnant?*
8. Are you over the age of 65 and not accustomed to vigorous exercise?*
9. Is there any other good physical reason not mentioned here why you should not follow and activity programme if you wanted to?*
If you answered Yes to any of the above question please provide further detail including dates where relevant. You should also talk with your doctor BEFORE you commit to this programme.
Please tick the box below to agree with our Terms & Conditions*
- I have read and agree to the Terms & Conditions
Please tick the box below to agree with our Disclaimer*
- I have read and agree to the Disclaimer
Signature Retreat@home Quantity*
Price: £ 597.00
One Week Weight Loss Retreat@Home
Credit Card
Card Details
Cardholder Name
Name
This field is for validation purposes and should be left unchanged.

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