Fasting Retreat Application

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*

Have you ever done any fasting or water fasting before? If yes, what type and how many days.*

Have you ever done any detox or cleansing protocols. If yes, please specify which detox protocols.*

Have you ever researched and or practiced shamanism? If yes, please explain.*

Why do you want to come to a Earther Academy Water Fasting & Detoxification Retreat?*

Have you been encouraged, recommended or pushed to attending an Earther Academy Retreat? If any apply, please specify.*

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

Are you open to receiving new education?*

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Have you ever done any fasting or water fasting before. If yes, what type and 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