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

Fasting Detox Expression of Interest & Application

About The International Wellness Farm

Retreats

Wellness Farm

Join our Community

what’s happening at International Wellness Farm

YOUR FREE COPY IS
ON ITS WAY.

Your Free Copy of
The Secrets of Detox

Discover the

Lost
SECRETS TO DETOX, RESET & REGAINING LOST VITALITY

Fasting Detox Expression of Interest & Application

About The International Wellness Farm

Retreats

Wellness Farm

Join our Community

what’s happening at International Wellness Farm

YOUR FREE COPY IS ON ITS WAY.

Your Free Copy of The Secrets of Detox

Discover the

Lost SECRETS TO DETOX, RESET & REGAINING LOST VITALITY

YOUR FREE COPY IS
ON ITS WAY.

Your Free Copy of
The Secrets of Detox

Lost
SECRETS TO DETOX, RESET & REGAINING LOST VITALITY