Fasting Form

Fasting Detox Expression of Interest & Application

FASTING RETREAT EXPRESSION OF INTEREST If you are interested in participating in the upcoming Fasting Retreat, please complete this form. The form is a general health intake form, which is a prerequisite for all fasting participants (even if you have fasted with us before). Once reviewed, you will receive an email to the address you provide below which will contain an invitation to a Zoom/Skype chat to discuss your unique needs.

"*" indicates required fields

1Biographical Data

2Emergency Contact Information

3General Information

4Fasting Brackground Information

5Health Status

6Physical Health

7Food Notes

8Drug Notes

9Psychological

10Submit

Enter the data requested below.

Name*

First Last

Email*

Enter Email Confirm Email

Home Phone Number*

Cell Phone Number*

Address*

Street Address City County / State / Region ZIP / Postal Code Country

Please provide an emergency contact below.

Name*

Enter the name of someone you trust who we can contact in case of an emergency.

First Last

Relationship*

What is your relationship to/with this person?

Emergency Contact Phone Number*

Please provide the best phone number for your emergency contact person.

Please answer the questions below.

Your Birthdate*

When were you born?

Month

Day

Year

Occupation*

What do you do for a living?

Gender*

Weight*

Height*

Please provide information regarding your experience with fasting.

Have you fasted before? (drinking clear liquids only)*

Yes

How long?*

How many days long did you fast for?

What did you fast with?*

What did you consume while fasting? (water, juice, etc.)

Have you participated at a fasting retreat with International Wellness Farm?*

Yes

Please specify when and where.*

Please select the boxes for any condition that applies to you either now or in the past.

Diabetes or high blood sugar*

Now

Past

Please specify – Type 1 or Type 2*

Type 1

Type 2

Arthritis

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Asthma

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Bone or Joint Problem

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Bowel Disorder (crohn's, colitis, etc.)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Cancer

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Candida Albicans (yeast infection)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Cardio-vascular disease, Heartattack or other heart condition

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Dizziness or Loss of Balance or Consciousness

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Epilepsy or seizure disorder

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Hypertension/high blood pressure

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Hypoglycemia (low blood sugar)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Immune system imbalance (Lupus, Epstein-Barr, HIV, etc.)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Liver Disease (Hepatitis, etc.)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Nervous system disease (M.S., Parkinson's, etc.)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Are you Pregnant or do you think you may be?*

Yes

Prescription drugs

Select only if applicable

Now

Past

Prescription Drugs (specify past and current)*

Thyroid problems

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Urinary tract disorder (kidney, bladder)

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Weight loss or gain

Select only if applicable

Now

Past

Please specify the Date Diagnosed and Current Status*

Please answer the following questions.

Do you have chest pain during physical activity?*

In the last month, have you experienced chest pain when not doing physical activity?*

Do you have a hearing/vision or structural condition that limits activity in any way?*

Do you weigh more than 20lbs under the normal weight charts or under your healthy weight? If so what treatments have you undergone and when?*

Please answer the following questions.

Do you have any food sensitivities? If so, which foods?*

Do you currently experience food binges? If so, what are your trigger foods?*

Do you have a history of an eating disorder such as anorexia, bulimia, or compulsive over-eating?*

Do you have a current eating disorder?*

Are you currently using any of the following?

Select all that apply

Caffeine

Alcohol

Nicotine

Recreational Drugs

Medicinal Drugs

None

For those you selected above, please specify for each the Daily Amount, Frequency, and Type.*

(Example - Caffeine: 2 cups of coffee per day or Alcohol: 1 glass of red wine with dinner 2-3 times per week ...etc.)

Have you had a history of drug or alcohol abuse?*

Are you under current treatment?*

Please answer the following questions regarding your psychological health.

Do you experience panic attacks or frequent bouts of anxiety (presently or in the past)?*

Have you been in psychotherapy for an issue (presently or in the past)? If so was there a diagnosis?*

Have you ever been hospitalized for psychiatric or addiction reasons? If so, when and for what issues?*

Medications you are currently taking or previously took?*

Do you have any food or animal allergies?*

Yes

Elaborate*

How did you hear about/discover International Wellness Farm?*

A clear idea of what you want from the Retreat can significantly enhance the possibility of receiving it. If you have an intention for the Fast, please mention it here:*

Consent*

I agree to the privacy policy.

By checking you confirm that you read and accept our Privacy Policy

Doing this retreat was the best decision in my life. I’m feeling super super good. Energized and clear headed.

Jihane, February 2024 Fasting & Detox Retreat

It’s been life-changing. I feel like a completely different person than who I was when I walked in. The shifts happening in me are almost unbelievable. I never thought it would be possible for me to feel this good, and there’s no amount of thanks I can give to you and the Kambo for that.

Sarah, Sept 2022

If there was ever a smidgen left that the Kambô does not work that has COMPLETELY been eradicated. I got my Moon today ( sorry for the overshare) and I would be a ball of pain and a hot mess in pain. But today, absolutely nothing – no pain, *NO PAIN* THANK YOU GRATEFUL

Edhi, June 2022

Crying happy tears. After the Kambo, i don’t feel like putting anything bad into me.

Alex, Jun 2022 after a Kambo Retreat

I had the privilege of spending 9 days at Wellness Farm, and I am delighted to say I came back home feeling like new again. I went there physically, mentally, and emotionally exhausted and left there feeling it was one of the best investments I have made in myself.
I would unreservedly recommend a visit; the exquisite accommodation is set in acres of forests and meadows amidst perfect peace and calm and the sound of nature. The personal service I received from Christina and Malcolm was unsurpassable and was above and beyond in my view. Their dedication and diligence to the various wellness modalities in terms of alignment with my needs was evident and their compassion and guidance in understanding my requirements, making recommendations, and administering the treatments was very, very appreciated.

Jim, May 2022

My experience at Wellness farm was magical. The countryside surrounding the property is gorgeous, full of mysticism and there are plenty of ways to explore it available. My stay originally involved a 10 day orange juice fast, i was very spoilt to all the knowledge and treatments that were on offer.

I left Wellness with extensive knowledge on health, and protocols that i can use for my own health issues at home. But, most of all, i take home with me a new glowing physical health and an emotional awakening to the next level of my spiritual journey. I am deeply grateful, the changes are for life and these things are normally priceless. Thank you!

Susie, March 2023 (March Fasting and Detox Retreat)

I’ve just come back from a 10 day juice fast at The Wellness Farm. My intention before joining was to detox my body. It’s been 5 years since my last detox in Thailand so I felt I was overdue. I needed some motivation and information on how to clear my system (and how to keep it clean). I got all of that and so much more out of the retreat. I’d give it 11/10. The set up is fantastic, awesome nature to go walk around in and Malcolm and Christina are just so knowledgable and passionate about what they do. Fantastic place to meet likeminded people and get the motivation to move forward with my new lifestyle and healthy outlook on life. I’ll definitely be going back for some of the other things on offer.

Dave G, June 2023 June Detox Retreat

Fasting Detox Expression of Interest & Application

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