Personal Information
First Name
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Last Name
Arrival Date
Email
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Emergency Contact
Age
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Height
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Current Weight
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Occupation
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What is the main reason for you coming to Anahata Retreat Phuket?
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Health History
Have You Ever Been Hospitalised?
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If yes, please provide details:
Have You Detoxed Before?
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If yes, please provide details:
Please List Your Main Health Concerns:
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Do you have any serious injuries or ailments?
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If yes, please provide details:
Do you have any allergies or sensitivities?
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If yes, please provide details:
Do you take any supplements or medication?
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If yes, please provide details:
Have you had any abdominal surgery/Colonoscopy in the past 12 months?
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If yes, please provide details:
What role does sports and exercise play in your life?
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Do you have any children?
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If Yes, How many?
Did you have Natural birth or C section?
How long did you breast feed for?
Is your cycle regular?
Have you had any dental work: filling, crowns, implants?
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General Diet
List your general Breakfast meals:
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List your general Lunch meals:
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List your general Dinner meals:
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List your general Snack items:
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List your general Drink choices:
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If other, please list below:
Do you suffer from any of the above Colon Cleansing Contraindications
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If Yes, please provide more information:
Do you suffer from any of the above Full Fast Contraindications
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If Yes, please provide more information:
Goals
What do you do to balance stress?
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What is your Current Emotional State?
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What is the the most important thing you wish to change about your diet to improve your health?
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How do you want to feel on a daily basis?
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Anything else you want to share?
If you are human, leave this field blank.
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