Health Questionnaire

Thank you for booking with Anahata. In order to give you a better and more personal experience, we need to know some important things about your lifestyle and health. Please complete the details in this form so that we can get to know you better.

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PERSONAL INFORMATION

Name
Returning Guest?

Health History

Have You Ever Been Hospitalised?
Have You Detoxed Before?
Do you have any serious injuries or ailments?
Do you have any allergies or sensitivities?
Do you take any medication?
Do you take any supplements?
Have you had any abdominal surgery/Colonoscopy in the past 12 months?
Do you have or experience any of the following:
Are you currently breast feeding?
Are you pregnant?
If so, when is your baby due?
Do you have any children?
Are you:
Have you had any dental work: filling, crowns, implants?
Please select your cravings, if any:

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

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

Goals

Responsibility

Before beginning one of our programs, please be advised that your health is your own responsibility! We here at ‘Anahata Wellbeing Retreats’ do not profess to be medical authorities or advisors. Should you have any doubts about your health, medications, or any pre-existing conditions, please get in touch with your medical practitioner first.

Arrival time

  • We will not be responsible for late arrival, in regard to pre-cleanse drinks/ food missed and length of stay at Anahata Wellbeing Retreats.

Payment

  • All activities should be paid for before starting programs, treatments or workshops.

What to wear

  • To ensure that guests can enjoy Anahata Wellbeing Retreats’ services, please wear comfortable clothing for all treatments and workshops.

Social guidelines

  • Anahata Wellbeing Retreats respectfully request that all detox guests completely refrain from consumption of alcohol and smoking on the premises during their detox program.
  • Anahata Wellbeing Retreats’ therapists are proficiently trained, and all services provided within the Centre are strictly professional. Any inappropriate behaviors towards therapists will automatically result in ending the treatment. Anahata Wellbeing Retreats reserves the right to receive full payment for the treatment.

Payment and Cancellation Policy:

  • Any reduction to the number of days and/ or changes in dates will be referred to as a cancellation.
  • Cancellation notification received after confirmation to 30 days prior to arrival will result in a cancellation fee of 50% of the deposit payment
  • Cancellation notification received less than 30 days prior to arrival will result in a cancellation fee of 100% of the deposit payment
  • Full payment for the program must be completed upon arrival and before commencing the program. We have a no refunds policy for our detox and wellness programs once they have been started.

Age

  • Anahata Wellbeing Retreats only accepts detox and wellness guests who are at least 18 years of age, or have consent from Parents or guardians. Children are welcome at Anahata Wellbeing Retreats if they are accompanying their parents or guardians to Thailand.

Special Consideration

  • Whilst we are happy and capable to deal with medical conditions we recommend that if you have high blood pressure, heart conditions, are pregnant, have any pre-existing mental conditions or have any other medical complications you are advised to consult your doctors before signing up for any of our services. Kindly inform your therapist or the detox manager of any existing medical conditions prior to commencing any wellbeing programs at Anahata Wellbeing Retreats.

Disclaimer

  • Anahata Wellbeing Retreats’ treatments are provided for general wellbeing purposes only and are not intended to be a substitute for professional medical treatment for any condition, medical or otherwise. Anahata Wellbeing Retreats and its management and staff hold no responsibilities on all liabilities, claims, expenses, damages and losses, including legal fees, arising out of or in connection with the centre and spa treatments, services and/or facilities.

Anahata Wellbeing Retreats Release of Liability and Waiver

  • By signing this Release of Liability and Waiver, I will assume full responsibility for any risks, injuries, or damage, known or unknown, which I might incur as a result of participating in the program or activities or excursions. This includes, without limitation, my use of the resort and facilities, pool, steam room, parking area, beach, road or any equipment, and participation in any part of the program, activity, class, training or instruction.
  • I am voluntarily participating in the program or activities or excursion and assume all risk of injury or death to me or the contraction of any illness or medical condition that might result, or any damage, loss or theft of any personal property. I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge Anahata Wellbeing Retreats and its affiliates, employees, agents, representatives, successors and assigns from any and all claims or causes of action (known or unknown) arising out of my participation in the program, activities or excursions (including, but not limited to, our negligence).
  • This Release and Waiver of liability includes, without limitation, injuries which may occur as a result of (a) my use of any equipment or facilities which may malfunction or break, (b) our improper maintenance of any equipment or facilities, (c) our negligent instruction or supervision, (d) my slipping and falling while on the premises or on activities or excursions, and (e) my travel to or participation in the program.
  • I agree that neither I nor any person or entity acting on my behalf has filed or will file, charge, claim, sue or permit to be filed, charged or claimed, any legal or equitable action against any staff of Anahata Wellbeing Retreats and Twin Palms Resort, involving any matter occurring at any time or related in any way whatsoever to travelling to or participating in any of our programs or activities or excursions.

 

Anahata Wellbeing Retreats will not accept responsibility for any loss, damage or theft of valuables brought into the resort.

Emergency Contact

Name
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Terms & Conditions Acceptance
I confirm that I have read the Anahata Wellbeing 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 Wellbeing Retreats terms and conditions.