Detox Fasting Application

First Name

Last Name

Spiritual Name

Phone Number

Email Address

Date of Birth (mm/dd/yr)

Street Address

City

State / Province

Zip Code

Country

Please describe any health concerns you have. Include prescription and/or over-the-counter medications you are currently taking as well as any medical restrictions.

Do you have a history of gastrointestinal issues such as IBS, colitis, diverticulitis, or gastroenteritis?

If yes, have you been treated by a physician and do you have medical clearance to participate in this program (with or without restrictions)?

Yes

No

Have you ever experienced, been diagnosed and/or treated for an eating disorder such as bulimia, anorexia, or binge eating?

If yes, have you been treated by a physician and do you have medical clearance to participate in this program (with or without restrictions)?

Yes

No

Have you consulted your family practitioner or other health care provider about this fast? What were his/her recommendations?

Do you otherwise consider yourself healthy? If not, please explain.

Is there anything else we should know about you?

Have you ever fasted before?

Yes

No

For how long?

Was it under guidance?

Why do you want to participate in this fast?

I am fully aware that the purpose of the Sivananda Ashram Yoga Retreat is to provide an environment for people to practice sadhana (spiritual practice). The Ashram is not a spa; it is a place for spiritual advancement. I confirm and acknowledge that I am voluntarily participating in this spiritual detox program. I undertake to keep the teachers fully up-to-date on any changes in my physical condition and any symptoms of illness.

I agree

Signature

Date

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Detox Fasting Application

Detox Fasting Application

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