Health declaration
Nysnö retreat programs

Basic health status and medications. Provided information is used as a platform for the screening interview only and will be deleted after completion of the program.

The following health declaration and continued screening process means that you provide information regarding your physical and mental health so that Nysnö can make an assessment of the suitability of your participation in the retreat program. You thereby undertake to provide truthful information about your state of health, which is essential in order not to expose yourself or other participants to serious risks.

Before starting the retreat program, you need to sign a written agreement in which you certify that you have provided correct information to Nysnö regarding your state of health. In case of breach of the agreement, Nysnö has the right to reject you from the retreat program with immediate effect.

Name *

Age *

E-mail *

Food preferences or restrictions? *

Serious Allergies or similar?

Are you pregnant or trying to get pregnant? *YesNo

Do you regularly use any medication? *YesNo

if yes, which ones?

Do you regularly use any dietary supplement/natural medicine? *YESNo

If yes, which ones?

State known physical or mental illnesses in close relatives

Do you feel physically healthy? *YESNo

Do you have or have had problems with your heart or high blood pressure (as far as you know)? *YESNo

Do you have any chronic medical condition or illness? *YESNo

If yes, what?

Do you feel mentally healthy? *YESNo

Do you have or have you had a psychiatric diagnosis? *YESNo

If yes, what?

During your life, have you been exposed to a traumatic experience or event (as far as you know)? *YESNo

Have you attempted suicide or other self-harming behavior during your life? *YESNo

Do you have or have you ever had an addiction problem? *YESno

If yes on any of the last three items, what?

I HAVE READ AND ACCEPT THE PRIVACY POLICY

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