Fasting Retreat Application - Earther Academy Retreats

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Height*

Weight*

Phone*

Email*

Skype Name*

Occupation*

Work History*

Primary Health Complaints*

Your personal health goals you would like to achieve*

Brief History of Health Complaints*

History of Medications (Include Past and Current)*

History of Vitamins, supplements, herbs, etc. (Include Past and Current)*

History of Surgeries and Hospitalizations*

History of Drugs, Caffeine, and Alcohol. (Include Past and Current)*

Current sleeping patterns*

History of Exercise patterns*

History of Diet (Include Past and Current)*

Frequency of Bowel Movements/Day/Week*

Have you ever done an enema? If so please explain*

Are you prepared to make diet and lifestyle changes to improve your health?*

Are you open to receiving new education?*

Have you ever fasted on water only before? If yes how many days?*

How long have you been practicing Terrain Modification Protocols?*

Are you currently an Earther Member*

Comments

Any other information you would like to submit.

Terrain Modification Retreat Application