Retreat Questionnaire First Name Last Name Address 1 Address 2 City State/Province Zip/Postal Code Country Email Phone Number (###) ### #### Please check ONE diet that you feel best describes your eating habits: Vegan (does not eat animal products) Vegetarian (eats eggs and honey) Pescatarian (eats fish and eggs) Omnivore (eats animal products-meat, fish &eggs) If you selected Vegan do you eat local honey? Yes No Restrictions-Please check all that apply to your current diet: Gluten Free Paleo Soy Free Dairy Free Nut Free Sugar Free Other I am MEDICALLY ALLERGIC to the following items: Meaning that you have been tested and confirmed that this is highly dangerous to your health, even in small, limited doses. If you have a medical allergy that doesn't allow that food item to even be cooked in your vicinity, please email us to discuss embracespaceretreats@gmail.com I have a sensitivity to and/or try to avoid the following items: This might mean you get an upset stomach, lethargy, etc, and you try to avoid this item, but having it near you won't send you rushing to the hospital I am most excited about eating: I dread that I might eat: My favorite food or meal is: I didn't see a space for it but I really need to tell you something specific about my diet: How do you view yoga: Personal journey Spiritual journey Journey to peace Physical exercise All of the above None of the above How often do you practice yoga? Please provide flight/travel information as we want to plan accordingly so everyone has a successful trip home Would you be interested in a day in the city (Waikiki) Any other questions, comments or concerns? Please let us know! We cannot wait to retreat with you! Thank you for filling out this survey!
