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WELLNESS RETREAT FOOD & ALLERGY QUESTIONNAIRE

Birthday
Month
Day
Year

Emergency Contact Information

Medical Information

Do you have any diagnosed medical conditions we should be aware of?
Yes
No
Do you take any daily medications?
Yes
No
Do you carry an EpiPen or emergency medication?
Yes
No
Do you have any food allergies or intolerances?
Yes
No
Type of reaction(s) experienced (check all that apply):
Severity of reactions:
How quickly do reactions occur after exposure?
Immediate
Within 30 minutes
Delayed (hours later)

Dietary Preferences & Restrictions

Confidentiality Statement


All personal and health information will be kept confidential and used only for your safety and wellness during the retreat. Please complete this form at least 7 days before the retreat date.

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