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Bali Retreat Prep Form

To help our team serve you better, please complete and submit the form below. Some of the fields may already have details from previous submissions, please update them as required.

We're looking forward to seeing you in Bali and supporting you on your journey.

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First Name

Last Name

Date of Birth

Previous Occupation

Current Occupation

What are the main outcomes you would like from your Health Dynamics Retreat program (in order of importance)?

Do you have any present symptoms that you are suffering from on a daily basis that you would like to change?

Have you tried to solve this problem in the past and if so how successful were you?

Are you taking any medication? (name, dosage, how long and reason)

What medications have you been taking in the past?

Do you have any allergies or intolerance?

Diagnosed medical condition?

Past health history and or operations/surgery?

Blood pressure?

Family medical history? (mother, father, siblings and grandparents)

Reproductive History (details of your period, pregnancies and/or miscarriages)

Do you exercise or participate in any sports? If so, please include what you do and how many times a week.

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