Sustainable Wellness retreat | Best Health Retreat In India

Name of wellness programme enrolled in: (Choose One)

Key reason for your visit: (Choose one or multiple)

Other. Please specify

What is your general state of health? Please specify any specific weak areas that you would like to work on.

Do you suffer from any specific illness like cancer, diabetes, hepatitis, others? If yes, what has been the duration of the illness?

Have you had any major or minor surgeries? Please specify the approximate time period?

Lifestyle Information: Are you an active smoker?

Yes No

If yes, how many cigarettes do you smoke in a day and since when?

Do you drink alcohol?

Yes No

Please specify the frequency.

Do you exercise regularly?

Yes No

If yes, please specify the frequency in a week and type of exercise.

How many hours of sleep do you get on average?

Choose one of the sleep patterns most suitable to your routine.

Are you easily emotionally upset? Choose

Yes No

Do you feel muscular tension?

Yes No

Do you regularly and easily feelunder pressure?

Yes No

Do you relax on weekends or take vacations regularly?

Yes No

If yes, how frequently?

How many hours do you work per day?

Muscular-Skeletal System

Have you had any accidentsor injuries?

Yes No

If yes, please specify the approximate time period.

Do you have any metal plates/pins in the body?

Yes No

Do you suffer from any of the below:

Leg cramps Back/ neck stiffness or pain Stiff joints Other

Circulatory System: Do you suffer from any of the below ailments?

If yes, please specifyduration since or when was the surgery.

Gynecological History: Are you pregnant or have had children? Did you go through a normal delivery or had a caesarean?

Do you suffer from any of the below?

P.M.T Menopause Hormone Imbalance

Do you take any HRT(Hormonereplacementtreatment)supplement? If yes,which ones?

Nervous System: Have you previously suffered or are suffering from any of these ailments?

Digestive System: How would you rate your appetite? Choose one.

Good Poor Erratic

How would you rate your digestion and bowel movements? Choose one

Regular Poor Erratic

Do you suffer from any of the below?

Ulcers Constipation IBS (irritable bowel syndrome)

Immune System: Are you prone to any of the below conditions? Is yes, how frequently?

Are you undergoing any other medical treatment? If yes, please specify what.

Are you on any regular off the shelf drugs? If yes, please specify which ones.

Do you take any other supplements? If yes, please specify which ones.

Are you consulting any other practitioner like Osteopath, Ayurveda, Naturopath, Homeopath, and Acupuncturist? If yes, for what ailment.

Diet Information: How many meals do you eat in a day?

Which is your biggest meal?

Do you eat in between meals? If yes, how frequently?

Do you have any food aversions or allergies?

In a week, how many times do you eat the below. Please specify a number.

I hereby confirm that the information provided above is accurate to the best of my knowledge. I understand that this information will be used by the Dharana Retreat team to personalize my wellness experience and ensure my safety during the program. I consent to the use of my data for internal assessment and program planning, in accordance with applicable privacy laws. I acknowledge that participation in wellness activities is voluntary and that I have disclosed any health concerns or conditions relevant to my participation.

STEP INTO THE DHARANA WAY OF LIFE

To pick the perfect wellbeing programme for your needs contact us, in the strictest confidence, with some initial personal details. We’ll then be in touch to help guide your choices.

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Questionnaire

Dharana General Wellness Questionnaire

STEP INTO THE DHARANA WAY OF LIFE

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