Your Name:
Your E-Mail Address:
Phone Nr: (incl. country code)
Street Address:
City :
State / Province:
Zip / Postal Code: Country:
Gender
Age
Suggested Arrival Date:
Date of Birth:
Weight:
Height:
Waist Circumf:
Wrist Circumf:
Blood Pressure: Systolic: / Diastolic:
Resting Heart Rate (beats per minute):
*Body Mass Index:
*Body Fat %:
Please specify why you decided to come on a retreat and why
NB&M Retreats :
What are your expectations and what would you like to
achieve:
Could you be
pregnant or are you attempting to become pregnant?
Do you
regularly take birth control medications?
Are you
currently menstruating or expect to do so within days?
Are you over 45
years of age and has one or more of the following:
Currently smoke
a pipe, cigars or cigarettes?
Have a high
cholesterol level?
Have a family
history of heart attacks or strokes?
Have you ever had or do you currently have...
Asthma, or
wheezing with breathing, or wheezing with exercise?
Frequent or
severe attacks of hay fever or allergy?
Frequent
colds, sinusitis or bronchitis?
Any form of
lung disease?
History of
chest surgery?
Behavioral
health problems?
Epilepsy,
seizures, convulsions ?
Reoccurring
migraine headaches ?
History of
blackouts or fainting (full or partial loss of
consciousness)?
History of
recurrent back problems?
History of
back surgery?
History of
diabetes?
History of
back, arm or leg problems following surgery, injury or
fracture?
Inability to
perform moderate exercise
History or
high blood pressure ?
History of any
heart disease?
History of
heart attacks?
Angina or
heart surgery or blood vessel surgery?
History of ear
or sinus surgery?
History of ear
disease, hearing loss or problems with balance?
History of
bleeding or other blood disorders?
History of any
type of hernia?
History of
ulcers or ulcer surgery?
History of
drug or alcohol abuse?
Click here to
access our Body System Evaluation Software
Fill-in the results (score) of the BSE (Body System
Evaluation) below :
1. Digestive System:
2.Intestinal System:
3.Circulatory System:
4.Nervous System:
5.Immune System:
6.Respiratory System:
7.Glandular System:
8.Urinary System:
9.Structural System:
10.Nutrition:
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