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Health Questionnaire
The details collated on this sheet is for informational purpose and will only be used as a basis to guide on how we can best help you benefit on the program that you signed up for. If you have any concerns about your health, consult your general practitioner. All information provided during the retreat does not imply endorsement of third-party services or products and the retreat center cannot provide any health and medical advice.
Date of sign up *
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Name
Your answer
Nickname
Your answer
Occupation
Your answer
Age
Your answer
Date of Birth
MM
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DD
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YYYY
Home Address
Your answer
Email address
Your answer
Mobile number
Your answer
Contact Person in case of Emergency
Your answer
Children & Age
Your answer
Program
Blood Pressure
Your answer
1 .Sleeping Pattern
2.Type of Exercise
Your answer
3.Frequency of Exercise
4.Duration of Exercise
Your answer
Your answer
5.Sweating
6.Diet habit
Your answer
7.1Usual Breakfast
Your answer
7.2 Usual Lunch
Your answer
7.3 Usual Dinner
Your answer
8. Alcohol
8.1 Alcohol Capacity
8.2 Frequency of alcohol intake
Your answer
9. Smoker
9.1 Number of Cigarette Consumed
10. Hunger just before meals
11.Daily water intake
12. Fasting Experience
Your answer
12.1Type of Fasting
13. Present Diseases declared by a doctor
Your answer
14. Do you Have any allergic symptoms? (please provide a detailed list )
Your answer
15. Any History of Operation ( please provide month and year if applicable)
Your answer
16. Do you have any maintenance medicine?
Your answer
16.1 Habits of using medicine
16.2 Type(s)of Medicine taken
Your answer
17.Bowel movement
18.Urination
19.Gas problem
20.Body pain ( Please be specific on what body parts
Your answer
21.Menstruation
22.Congestion build up
23.Cough
24.Skin
25.Itchiness
26.Anxiety or Depression
27. I am concerned about my
Your answer
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