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Health Questionnaire

Start the conversation to established good relationship and business.

Personal Information

Connect With the kala for Exclusive Stays and Support.

First Name *

Last Name *

Arrival Date

Returning Guest?

YesNo

Email *

Phone *

Emergency Contact

Age *

Height *

Current Weight *

Ideal Weight *

Occupation *

What is the main reason for you coming to Anahata Retreat? *

Have You Ever Been Hospitalised?

YesNo

If Yes, Please Provide Details:

Have You Detoxed Before?

YesNo

If Yes, Please Provide Details:

Please List Your Main Health Concerns:

Do you have any serious injuries or ailments?

YesNo

If Yes, Please Provide Details:

Do you have any allergies or sensitivities?

YesNo

If Yes, Please Provide Details:

Do you take any medication?

YesNo

If Yes, Please Provide Details:

Do you take any supplements?

YesNo

If Yes, Please Provide Details:

Have you had any abdominal surgery/Colonoscopy in the past 12 months?

YesNo

If Yes, Please Provide Details:

What role does sports and exercise play in your life? *

Do you have or experience any of the following:

Type 1 DiabetesType 2 DiabetesConstipationHigh Blood PressureLow Blood PressureChronic FatigueHeart DiseaseIBSDiarrheaGasBloatingWhite Coating on TongueAthletes FootVaginal ThrushPoor MemoryJoint PainHeadaches/MigrainesSkin IssuesInsomniaFatigueDizzynessChest PainAcid RefluxStomach PainJaw PainNauseaFluid RetentionCold Hands/FeetHair LossSwollen AnklesMenstrual Problems/PMSdiverticulitisinsomniaUTI

Please list any other current medical conditions:

Are you currently breast feeding?

YesNo

Are you pregnant?

YesNo

If so, when is your baby due?

YesNo

Do you have any children?

YesNo

If Yes, How many?

Did you have Natural birth or C section?

Are you:

Perimenopausalmenopausalpost-menopausal

Have you had any dental work: filling, crowns, implants?

YesNo

What percentage of your food is home cooked?

Where do you get the rest of your food from?

List your general Breakfast meals: *

List your general Lunch meals: *

List your general Dinner meals: *

List your general Snack items: *

List your general Drink choices: *

Please select your cravings, if any:

SugarCoffeeCigarettesAlcoholOther

If other, please list below:

Do you suffer from any of the above Colon Cleansing Contraindications

YesNo

If Yes, please provide more information:

Do you suffer from any of the above Full Fast Contraindications

YesNo

If Yes, please provide more information:

What do you do to balance stress? *

What is your Current Emotional State? *

What is the the most important thing you wish to change about your diet to improve your health? *

How do you want to feel on a daily basis? *

Anything else you want to share?

First Name *

Last Name *

Phone Number *

Email *

Please upload your Country Issued Identity Card or Passport.

I Agree I confirm that I have read the Anahata Retreats Terms and Conditions policy agreement and agree to all conditions set forth without exception. I also confirm that the information I have provided is correct to the best of my knowledge. By ticking the confirm box, I am agreeing to the equivalent of an electronic signature stating that I am in full agreement with all Anahata Retreats terms and conditions.

I Agree I confirm that I have read the Anahata Retreats Terms and Conditions policy agreement and agree to all conditions set forth without exception. I also confirm that the information I have provided is correct to the best of my knowledge. By ticking the confirm box, I am agreeing to the equivalent of an electronic signature stating that I am in full agreement with all Anahata Retreats terms and conditions.

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