Wellness Questionnaire - Eden Health Retreat

Step 1 of 10

A. Program Commencement Date
Date*
Date Format: DD slash MM slash YYYY

B. Your Details
First and Last Name*
Your Preferred Name
Date of Birth*
Date Format: DD slash MM slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Personal Phone Contact*
Email*

C. Gender
Gender*
- Male
- Female
D. Occupation
Your Occupation*

E. Emergency Contact
Name*
Relationship
Contact Number*
Alternative Contact Number
Email*

F. Medical Insurance
Do you have hospital insurance?*
- YES
- NO
Do you have ambulance cover?*
- YES
- NO
(Please ensure you bring your Medicare and health care card)

H. Cardiac Risk Assessment
What is the main reason you have booked a stay at Eden. Please feel free to list any goals that you wish to achieve during your time with us
I. Required Medication
Do you require medication?*
- YES
- NO
Please list current medication name and dosage.
Guests who are currently on medication or pharmaceutical treatments are responsible for their continued use while in attendance at Eden as per the advice of their medical practitioner or chemist.

J. Our Healthy Food Philosophy
Our set menu has been carefully formulated to ensure your food experience is nutritionally balanced and satiating to fuel the various activities and experiences you will enjoy during your stay. It has been especially created to ensure you leave Eden feeling nourished and inspired to continue eating well. All our meals are gluten free and provide a wide selection of fresh, seasonal, local and organic fruit and vegetables. We serve a small amount of organic dairy, as well as a combination of both sustainably-sourced seafood and organic white meat. We also utilise a variety of plant-based proteins, whole grains, nuts and seeds. If you have any allergies or intolerances or you’re vegan or vegetarian, our chefs will cater to your needs using the information provided below.
Do you have any food allergies or intolerances?
- Yes
- No
If yes, please specificy.
Please tick if you are:
- Vegan
- Vegetarian
Are you pregnant?
- Yes
- No
Please provide any important information regarding your dietary requirements.
If you have any other dietary concerns please outline them below, or request a short consultation prior to your arrival with our chef.
Please note: if you have any severe allergies that may lead to anaphylaxis, we require you to bring your own EpiPen®. Please consult your physician prior to arrival if you do not have one.

K. Physiological Assessment
Do you have any areas of pain or discomfort e.g muscular or joint pain?*
- YES
- NO
If YES, please provide details.
Please note: due to operational and safety requirements, there is a maximum weight restriction of 110kg for some adventure activities conducted at Eden Health Retreat. Please contact on 07 5533 0333 if you have any queries regarding this matter. We do have close links with local medical practitioners should the need arise.

L. Acknowledgement / Release
Eden’s property is expansive and most of the accommodation is located at the top of a steep hill. It is a prerequisite to be able to make your own way by foot to all areas during your stay

Please note, the closest hospital is 45 minutes away by car.

We do have close links with local medical practitioners should the need arise.

PLEASE BE AWARE YOU WILL BE REQUIRED TO SIGN AN ACKNOWLEDGEMENT / RELEASE ON YOUR CHECK IN. PLEASE CALL IF YOU HAVE ANY QUERIES 07 5533 0333

Eden is an alcohol- and drug-free environment. If any guest is found to be affected by drugs or alcohol on arrival, they will be asked to leave the premises.

There is no coffee served at Eden. A selection of herbal teas will be available during meals for your enjoyment. We suggest that guests cut down on their coffee intake at least one week prior to their arrival. Please note that mobile phone coverage is very limited. However we do have landline phones in the reception area available for use.
Please provide any further information that you feel is relevant to your stay at Eden.
I understand that Eden Health Retreat is a private and personal experience for each participant, which is up to the individual to share in their own way. I therefore agree to respect the confidentiality of all participants, including all remarks and experiences of other participants. I will not share any images or videos of other guests without their knowledge or approval. I agree to keep all fellow guests’ material private and confidential. All the information I have stated in the Guest Wellbeing Form and supplementary documents is true and correct to the best of my knowledge. I have read and understood the Booking Terms and Conditions, Disclaimer and Confidentiality Agreement and agree to abide by them.*
I agree

Step 1 of 10

A. Program Commencement Date

B. Your Details

C. Gender

D. Occupation

E. Emergency Contact

F. Medical Insurance

G. Things We Need To Know

H. Cardiac Risk Assessment

I. Required Medication

J. Our Healthy Food Philosophy

K. Physiological Assessment

L. Acknowledgement / Release