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Questionnaire

We're very excited to have you join us here at Quintinha do Mar Retreat. 

In order to best help on an individual basis please fill in the questionnaire below which indicates to us your current health status and how we can help during your retreat. 
 

It is worth mentioning that your questionnaire is confidential and only shared with your approval with our staff members which include our teachers, massage therapist & medical advisors.

Personal info

Which retreat have you booked into?

Select one option

How did you first hear about Quintinha do Mar Retreats?

Select one option

Emergency Contact

Medical History

1. Past or current medical problems

Please tick all that apply and / or use the text box below

2. Other medical problems

If yes to any medical problems, please provide details

3. Are you taking any medication (or have in the last six months)?

4. Do you have any food allergies/intolerances/preferances *

Do you think this retreat can help you? If yes, how ?

What would you like to achieve from Quintinha do Mar Retreats?

Thanks!

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