Health Questionnaire

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

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PERSONAL INFORMATION

Name
Date of Detox Retreat
Returning Guest?
Relationship Status

EMERGENCY CONTACT

Name

HEALTH HISTORY

Have you ever been hospitalized?
Have you ever detoxed before?
Do you have any serious injuries or ailments?
Do you take any supplements or medication?
Do you have any allergies or sensitivities?
Have you had any abdominal surgery in the past 12 months?
Do you have or experience any of the following:
Do you have any children?

GENERAL DIET

Please select your cravings, if any:

Colon Cleansing Contradications:

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?

Full Fast Contradictions:

Children under 18
Adults over 70 years old or severely weak
Pregnant women
Severe Adrenal Fatigue
Diabetes Type 1 and Type 2Cirrhosis 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
EpilepsyPre-existing heart defects
Thyroid problems
Hypertension if not medicated

Do you suffer from any of the above Full Fast Contraindications?

GOALS

DISCLAIMER IMPORTANT NOTE

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

Payment
All activities should be paid for prior to the commencement of programs, treatments or workshops.

What to wear
To ensure that guests can enjoy Anahata's services, please wear comfortable clothing for all treatments and workshops.

Social guidelines
Anahata Wellbeing respectfully requests that all detox guests completely refrain from consumption of alcohol and smoking on the premises during their detox program.
Anahata Wellbeing’s 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 reserves the right to receive full payment for the treatment.

Payment and cancellation policy.
A 24-hour notice is required to re-schedule the appointment or workshop. Any cancellation with less than 3 hours’ notice will incur a 50% cancellation fee. Full charges will be imposed for a no show.
A 21 day notice is required to re-schedule a well-being or detox program, subject to space availability. Any cancellation with less than 21 days notice will incur a 25% cancellation fee. Full payment for the program must be completed upon arrival and before commencing the program. We have a no refunds policy for our detox programs once they have been started.

Age
Anahata Wellbeing only accepts detox guests who are at least 18 years of age, or have consent from Parents or guardians.
Minors are welcome at Anahata Wellbeing if they are accompanying their parents or guardians.

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.

Disclaimer
Anahata's 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 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 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 my 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 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 and any partner 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 will not accept responsibility for any loss, damage or theft of valuables brought into the resort.

I confirm that I have read the Anahata Wellbeing Resort 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