Functional Medicine Retreat Application - Kona, Hawaii Question Title * 1. Why do you want to attend this retreat? What attracted you to the retreat? Question Title * 2. What is your Name, Email, Phone Number, and Room Preference? Are you planning on sharing a room with someone? Question Title * 3. Are you familiar with Functional Medicine or have a science background? Yes No Question Title * 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? Yes No Question Title * 5. Please list your top 3 symptoms or conditions you would like to change and have addressed at this retreat. Question Title * 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 Question Title * 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 Question Title * 8. Do you have dietary restrictions? Are there foods you do not like? Question Title * 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 Question Title * 10. How did you hear about this retreat? Social Media Friend or Family Website Email Other Done