Health and Wellness Intake Form by stw43683

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                                              Health and Wellness Intake Form
The information you provide by completing this questionnaire will allow our medical doctors to define your personal program before your arrival.
Following your arrival, you will be offered a medical consultation on the basic of which adjustments to the program may be made. Thoroughness
in the information you provide will ensure we design a plan relevant to your needs.


Last Name:                                           First Name:                                        Title:                  Gender:      Female


Date of Birth:                                                     Time of Birth:                                  Age


Height:                                 Weight:                        Telephone Number:                               Email

Address                          City                              Country      Albania                                  Zip Code


1. Please, indicate your main health concern:
                                                                                                                                           Diabetes
    Stress in daily life                          Colds & infections                         Overweight or weight loss
                                                                                                                                          Skin disease
    Rejuvenation                                  Autoimmune condition                       Sexual problems
                                                                                                                                           Cancer
    Alcohol / Drug Use                            Sleeping problems                          Easy to bruise
                                                                                                                                          Hair loss
    Pain Syndrome                                 Fertility                                      Smoking
                                                                                             High blood pressure                          Other
                                                  Constipation / GI Problems
    Joint pains, swelling,
    limitation of movement
2. Please, describe the nature of your health concern in detail and list any medical conditions, past and present.




3. Please list medications utilized during the course of the past six (6) months. Please, include vitamins and dietary supplements.

          Antacids                                Hormones                          Heart medication                      Chemotherapy / radiation
          Sleeping pills                          Steroids                          Pain medication                       Blood pressure medication

          Antidepressants                         Laxatives                          Fertility                            Cholesterol control medications

          Antibiotics                             Other

Please list the brand or generic name of medications utilized during the course of the past six (6) months.




4. Are you pregnant?                      If unsure, please indicate date of last menstrual period:

5. Please, indicate if have ever had or been diagnosed with any of the following conditions (check all that apply):

    Hypertension           If yes, please indicate highest blood pressure:                          What is your normal blood pressure?

    Hepatitis                        Kidney dysfunction                        Gall stones                         Heart dysfunction / heart attack

    Chest pain                       Adrenal dysfunction                       Seizures                            Pancreastic dysfunction

    Stroke                           Abdominal hernia                          Ulcerative colitis                  Abdominal / hormonal implants

    Anal fissure                     Liver condition                           Crohn's Disease                    Intestinal inflammation

    Colon polyps                     Intrauterine device                       HIV / AIDS                          Diverticulitis / diverticulosis

    Irritable Bowel Syndrome                                                                                       Colorectal tumor / cysts

   Other internal organ dysfunctions                 If yes, please specify:
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                                                 Health and Wellness Intake Form


6. Was your request quickly responded to? ?

   If yes, please indicate the reason for the surgery and the date the surgery was performed.




7. Have you had colon hydrotherapy or other colon cleansing treatment before?


8. Please, list the results you expect from Tao Garden Health Resort and your health-related goals.




9. Please, define your principal goal for your stay by checking any of the following that apply:

       Relaxation                      Forming Healthy Habits                  Learning about health                 Psycho-emotional support

       Weight loss                    Free time for swiming                    Spiritual growth                      Natural Treatment for
                                                                                                                     a medical conditions



10. Please, indicate the number of days you are able to allow for your stay.                  days

   The Medical Doctors will prescribe the duration of the program on the basis of your state of health and the health goals
   you have defined, as well as allowable time away from work and family.

11. Please, provide information regarding any known allergies you may have.


    Allergies to foods

Please, list the foods and drinks to which you are allergic and the associated reactions.




    Allergies to medications

Please, list the medications to which you are allergic and the associated reactions.




12. Are you following a defined dietary program?

If yes, please, provide information about the diet.
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                                     Health and Wellness Intake Form




 This document delineates the terms and conditions by which the guest agrees to abide for the duration of stay at
Tao Garden Health Spa & Resort, located at 274 Moo 7 Luang Nua, Doi Saket, Chiangmai, Thailand (hereafter referred
to as “Tao Garden Health Resort”).
  The scope of The Tao Garden Health Resort is to provide guests with progressive therapies designed to cleanse and
strengthen physical, mental, and emotional health. The services and products offered include educational classes, raw
and living (high-enzyme) meals, general fitness exercises sessions, massage, life and lifestyle coaching. The services
and products defined and delineated by medical personnel of TAO GARDEN HEALTH RESORT individually for the guest
signing hereunder shall hereafter be referred to as “the Program”. The person signing hereunder and either intending to
purchase a service or a product of TAO GARDEN HEALTH RESORT or having purchased a service or product of
TAO GARDEN HEALTH RESORT shall hereafter be referred to as “the Guest”.




       Printed name of the Guest:




      Signature of the Guest




                                                                                    Current Date        2/26/10



              Thank you for taking the time to complete the form.
        Please, click on the icon below to send us the completed form.
    We will contact you by book as soon as your program has been defined.
                   If you can not send the form by online please save this page to your file
                            then send by attachment to pakua@tao-garden.com

                 We look forward to welcoming you to Tao Garden Health Resort
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