1.Why do you want to attend this retreat? What attracted you to the retreat?

2.What is your Name, Email, Phone Number, and Room Preference? Are you planning on sharing a room with someone?

3.Are you familiar with Functional Medicine or have a science background?

Yes

No

*4.Are you interested in having Functional Medicine labs done prior to the retreat so you could discuss your results and use them to direct your learning experience?(Required.)

Yes

No

5.Please list your top 3 symptoms or conditions you would like to change and have addressed at this retreat.

6.How would you rate your willingness to make change to reach your health goals?

0

1

2

3

4

5

6

7

8

9

10

7.Do you find dealing with other people's personalities a challenge, or do you find yourself a 'go with the flow' type of person?

Dealing with other people's personalities is a challenge

Go with the flow type of person

8.Do you have dietary restrictions? Are there foods you do not like?

9.Are you interested in participating in extracurricular activities such as walking, hiking (relatively steep terrain), snorkeling, boogie boarding, surfing, and sightseeing? Select all that apply.

Walking

Hiking

Snorkeling

Boogie boarding

Surfing

Sightseeing

None

10.How did you hear about this retreat?

Social Media

Friend or Family

Website

Email

Other