Retreat-form

please complete the form below and we can have a chat about you joining us on a Life Right Retreat

  • STEP 1
  • EMPLOYMENT
  • PAIN

STEP 1

FULL NAME

Mobile number

email address

Full address inc. Postcode

DATE OF BIRTH

MARITAL STATUS

GENDER

NUMBER & AGES OF CHILDREN

HOW DID YOU HEAR ABOUT LIFE RIGHT (IF FROM A PERSON, PLEASE GIVE THEIR NAME)

Have you had both of your covid-19 vaccinations? (all those attending a Life Right Retreat are required to have had both covid 19 vaccinations)

EMPLOYMENT

OCCUPATION

EMPLOYER

YEARS IN CURRENT JOB

PREVIOUS OCCUPATION IF LESS THAN 2 YEARS

HEALTH DETAILS (PLEASE COMPLETE IN FULL)

NAME OF GP

GP PRACTICE

CONTACT NUMBER

Are you seeing a specialist of any kind at present?

If 'YES', for what are you seeing them for and what is their specialism?

WHAT MEDICATION ARE YOU CURRENTLY TAKING?

WHAT MEDICATION WERE YOU TAKING BEFORE BUT ARE NO LONGER?

BROKEN BONES IN THE PAST

ANY PREVIOUS ROAD TRAFFIC ACCIDENTS? (INC. DATES)

PLEASE LIST ANY OPERATIONS OR HOSPITALISATIONS IN LAST 10 YEARS (INC. DURATION)

ANY PREVIOUS X-RAYS

PLEASE DETAIL FROM CHILDHOOD TO PRESENT DATE ANY EVENTS, SITUATIONS, PEOPLE OR TRAUMA YOU FEEL MAY BE SIGNIFICANT IN HOW YOU ARE FEELING TODAY (WITH DATES IN A TIMELINE LIST) (inc. hospital visits or long periods of antibiotics)

PERSONAL INFO (CONTD)

DO YOU SMOKE

IF 'YES', HOW MANY PER DAY?

FOR HOW MANY YEARS?

DO YOU EXERCISE?

TYPE OF EXERCISE?

FREQUENCY

YOUR HEIGHT IN CMS

YOUR WEIGHT IN KGS

Please detail in this section what you would like help with on the retreat?

ARE YOU CURRENTLY EXPERIENCING ACHES OR PAINS? PLEASE DESCRIBE IN AS MUCH DETAIL AS POSSIBLE

Please describe in as much detail as possible, what we can help you with?

Confirmation

please type your name to confirm you have completed this form fully and not omitted any information

When you click SUBMIT, you will be taken to the payment authorisation page, where you will need to complete your payment card details