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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?

Yes No

Email

Phone

Emergency Contact

Age

Height

Current Weight

Ideal Weight

Occupation

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

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Health History

Have You Ever Been Hospitalised?

Yes No

If Yes, Please Provide Details:

Have You Detoxed Before?

Yes No

If Yes, Please Provide Details:

Please List Your Main Health Concerns:

Do you have any serious injuries or ailments?

Yes No

If Yes, Please Provide Details:

Do you have any allergies or sensitivities?

Yes No

If Yes, Please Provide Details:

Do you take any medication?

Yes No

If Yes, Please Provide Details:

Do you take any supplements?

Yes No

If Yes, Please Provide Details:

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

Yes No

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 Diabetes Type 2 Diabetes Constipation High Blood Pressure Low Blood Pressure Chronic Fatigue Heart Disease IBS Diarrhea Gas Bloating White Coating on Tongue Athletes Foot Vaginal Thrush Poor Memory Joint Pain Headaches/Migraines Skin Issues Insomnia Fatigue Dizzyness Chest Pain Acid Reflux Stomach Pain Jaw Pain Nausea Fluid Retention Cold Hands/Feet Hair Loss Swollen Ankles Menstrual Problems/PMS diverticulitis insomnia UTI

Please list any other current medical conditions:

Are you currently breast feeding?

Yes No

Are you pregnant?

Yes No

If so, when is your baby due?

Yes No

Do you have any children?

Yes No

If Yes, How many?

Did you have Natural birth or C section?

Are you:

Perimenopausal menopausal post-menopausal

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

Yes No

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:

Sugar Coffee Cigarettes Alcohol Other

If other, please list below:

Colon Cleansing Contraindications

Children under 18
Adults over 70 years old or severely weak
Uncontrolled/non-medicated stage 2/3
Hypertension Congestive Heart Failure Cirrhosis of the Liver
Carcinoma of the Colon
History of Aneurysm/Blood Clots
Fissure/Fistula
Severe Anemia
Pregnancy/First & Last Trimester
GI Hemorrhage/Perforation
Abdominal Hernia
Bleeding/Inflamed Hemorrhoids
Recent Abdominal Surgery
Renal Insufficiency
Active severe Diverticulitis, Colitis, IBS
HIV or any infectious disease
Pre-existing heart defects
Hypertension if not medicated
Do you suffer from any of the above Colon Cleansing Contraindications

Do you suffer from any of the above Colon Cleansing Contraindications

Yes No

If Yes, please provide more information:

Full Fast Contraindications

Children under 18
Adults over 70 years old or severely weak
Pregnant women
Severe Adrenal Fatigue
Diabetes Type 1 and Type 2
Cirrhosis or liver disease
Kidney Disease
Alcoholic
Gall Stone Disease
Severe Thyroid Malfunctions
HIV or any infectious disease
Lupus or severe immune dysfunction
Cancer or malignant tumour
Cardiovascular diseases
Serious cardiac problems or heart defects
Anorexia or other eating disorders
Malnourishment or malnutrition
Severe anaemia
Bleeding disorders of the stomach and intestines
Psychiatric disorders or severe Bi-polar Epilepsy
Pre-existing heart defects
Thyroid problems
Hypertension if not medicated
Do you suffer from any of the above Full Fast Contraindications

Do you suffer from any of the above Full Fast Contraindications

Yes No

If Yes, please provide more information:

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Goals

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?

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Emergency Contact

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.

On the edge of Koh Samui. In your own quiet world.

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