The Regeneration Diet Questionnaire

To make sure that you are able to go through this incredible process, we need to check for any allergies and learn more about your current health.

Please note that if you are in great health and haven’t experienced Covid, Long Covid or any Chronic Health issues, great! Our Retreat is not solely focused on those conditions, it can just be amazing for them which is why we ask about them below.

Our Regeneration Retreat process offers so many rejuvenating benefits to your overall well being. Even if you are in perfect health, you can still come away feeling even brighter, as well as truly rested.

Name *

First

Last

Age

Weight

Email *

Phone

1. What are your current dietary preferences?

i.e. carnivore, vegan, pescatarian

2. Do you have any food allergies or intolerances?

3. Do you have any underlying health conditions – past or current?

4. Are you under the care of a healthcare provider for an ongoing issue?

5. Are you taking any medication?

6. Are you taking any supplements or herbs?

7. Do you have a history or currently have an eating disorder?

8. Are you diabetic?

9. Do you have a diagnosed heart / blood pressure / liver / kidney condition?

10. Do you suffer with any digestive discomfort?

11. Do you have a diagnoses of either hypothyroidism or hyperthyroidism?

12. Are you pregnant?

13. Have you had Covid-19?

If your answer is "Yes" and you feel you may be struggling with Long Covid symptoms or know it to be the case, please also fill in the questions specific to this at the bottom of the form.

14: How are your bowel movements? Do you ever suffer from constipation?

15. How are your stress levels?

16. Do you meditate?

17. Have you carried out any fasting before?

18. If yes, how long for and how did you find it?

19. Do you have any concerns about fasting?

20. Have you ever been in Ketosis?

21. Are you a frequent snacker?

22. What attracted you to the Regeneration Retreat?

23. What would you like to achieve with your time with us?

If suffering with long Covid:

A: When did you have Covid-19?

B: What are your symptoms?

C: Are you under the care of a long Covid clinic / doctor?

D: What have you tried on your healing journey?

E: Have you improved during this time?

F: How was your health before Covid?