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Sound Sanctuary : Mini Retreat

Email *

Have you experienced coughing or high temperature, any other symptoms similar to flu?

Yes

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What brings you to Sound Sanctuary Retreat with Meditation and Ecstatic dance? *

How many times a week do you exercise

Excercise to keep fit

Once a week

At least twice a week

More than three times a week

Everyday

Other:

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Please state any emotional, mental or physical symptoms you are experiencing

Aches, pains, re-occurring thought patterns, emotional tendencies, any search for relief from a particular event/situation

When observing your breath do you mostly feel...

what is happening, I just can't do this

I'm a little confused, what is happening

What is the point, it is so boring

Ah just breathing, what an amazing feeling

How do you feel about Meditation ? *

A leisure activity such as: running, walking, horse riding, cycling

Hard work, I should do better

Hard work but not discouraging

I like a challenge

Easy

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Do suffer from any of the following? *

Nightmares

Palpitations

Breathlessness

Tinitus

Increased levels of persperation

Insomnia

None

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Are you on any medication?

please specify the type

Yes

Do you have any of the following? *

Please give detail if in recovery from an operation

Heart Problems

Glaucoma

Asthma

Eye/ Ear problems

Osteoporosis

Arthritus

High Blood Pressure

Low blood pressure

Hip replacement

Hiatus Hernia

Crohns

Epilepsy

Depression

Irritable Bowel Syndrome

Sciatica

Pregnant give details below

Knee Replacement

Shoulder dislocation

limb Amputation

None

Required

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