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Guest Personal Information
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Travel Insurance Details
In Case Of Emergency Contact
Home phone number
Work phone number
Physical activity readiness questionnaire and medical info (If Yes, Please explain)
Has your doctor ever said you have any heart problem?
Do you frequently suffer from chest or heart pain?
Have you ever had a heart attack?
Do you ever experience an irregular or racing heart rate during exercise or at rest?
Do you often feel faint or have spells of severe dizziness?
Has a doctor ever said that your blood pressure is too low/high?
Do you often have difficulty breathing?
Has a doctor ever told you that you have a bone or joint problem such as arthritis that has been aggravated by exercise, or might be aggravated with exercise?
Is there a good physical reason not mentioned here, why you should not follow an activity program even if you wanted to?
Are you diabetic?
Are you pregnant or have given birth within the last 2 months?
Do you have or had any injuries or orthopedic problems?
Do you have any other medical conditions not previously mentioned?
Are you currently taking any medication?
Do you smoke?
Do you currently have a disability or a communicable disease?
Please describe your current fitness level and exercise program (including cycling), if any
Do you practice yoga? How long and at what level?
Have you ever worked with a personal trainer?
Diet and Nutrition
Are you a vegetarian? What type?
Do you drink alcohol? How much per week?
Please outline personal goals during your stay with us
Please check to confirm that you’ve read and answered the above questions completely and affirm that you have no known medical problems that would restrict your ability to participate in Pure Scapes Retreats holidays.
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