CONFIDENTIAL HEALTH QUESTIONNAIRE: 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Email * Name * Surname * Prevention & health maintenance Physical Emotional Mental Spiritual Improvement of a minor health condition Physical Emotional Mental Spiritual Improvement of a chronic condition Physical Emotional Mental Spiritual Do you have any previous Fasting Detox experience? * Yes No Are you currently on any Medication? * Choose Yes No Fasting Experience How many times? * Choose 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Longest Fasting Detox days? * Choose 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 Have you done a detox at Health Oasis? * Choose Yes No When and for how many days each time 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 Programs duration days ? 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Have you experienced any serious health reactions during any of the fasting detox in the past?* Choose Yes No Specify * Are you currently on any Medication? * Choose Yes No Specify * names, dosage, conditions for, since when each Specify * names, dosage, conditions for, since when each Recent Alcohol Addiction? * Choose Yes No Recent Drug addiction? * Choose Yes No Specify * Are you currently taking any supplements, herbs or alternative medicine? * Choose Yes No What supplement, herb, or alternative medicine are you taking? Specify * Have you had any surgeries/operations? * Choose Yes No Specify what & when * Any injuries? * Choose Yes No Specify what & when * Do you have any pre-existing Health Issues? * Choose Yes No Specify * Have you been diagnosed with any Medical Condition? * Choose Yes No Specify * Have you suffered any emotional traumas past or recent? * Choose Yes No Specify * Name of International Cover Health Insurance *: Specify certificate No and card No * Emergency contact name and contact No and email *: Specify * I have discussed my upcoming detox with my doctor and have been given consent & guidelines by him/her * Yes No I have not discussed this with my doctor but I take full responsibility for my health and any effects I may experience during or after my detox program * Yes I confirm that all above information is accurate and I consent to notify Health Oasis Resort if any of the above information changes between this day and my detox starting day at the Health Oasis*: Yes Conditions & Disclaimer Acknowledgments I clearly understand that the Health Oasis Resort a holistic health retreat, NOT a medical facility. I DON’T expect the detox program to necessarily fix any health conditions - but simply provide me with well researched & tested holistic advice and guidance, to integrate onto my healing journey. I understand that whichever uncomfortable effects I may experience during the program are a direct result of my previous life choices, flushing out - and NOT caused by the program or the people around me. It is like pouring alcohol on a wound and interpreting the temporary discomfort as a result of the pre-existing wound rather than blame the alcohol. Ultimately this is a self-healing journey which I consciously & sincerely make and I assume full responsibility for all the decisions I make during it – especially if I don’t follow the program as instructed and/or continue/alter/stop any existing medications I am on. I fully comprehend that Health Oasis Resort’s role is not to fix me - but to assist me heal myself and I have already made this self-healing commitment. I comprehend and consent to the above and I am ready for this healing journey. I will respect : my fellow guests and their own journeys, the sincere intent of Health Oasis to assist me in my healing journey and it is up to me to allow that help, my inner commitment to heal, even if it may be uncomfortable at times. I consent to the following: I will refrain from taking any medications/supplements without prior notifying the Health Oasis, as they may interfere with my program or/and cause me unpredictable harm. I will refrain from doing any healing modalities or activities outside the Health Oasis, as they may interfere with my program or/and cause me unpredictable harm. I will refrain from any strenuous physical activity inside or outside the Health Oasis during my program, as it may unnecessarily drain my energy and cause unpredictable reactions. I will refrain from going to any island tours for more than 2 hours, as I may unnecessary stress myself due to the exposure to a busy environment. If I do so, I understand that I am taking a risk and assume responsibility for it. I will refrain from any self-destructive or negative behavior towards the Health Oasis staff or/and its other clients, and if I fail to do that, it will result in the immediate termination of my program. Any personal complaints I may have I will address them to the front desk or wellness managers and NOT share them with other guests, as it will interfere and poison their own detox experience. Any such behavior will result in the immediate termination of my program and my immediate departure from the Health Oasis Resort. I understand that if I decide to cut my program short or modify it, I won’t be able to claim any refunds. I understand that the Health Oasis has the right to determine in its discretion that I am unwilling or unable to follow the program instructions and after a warning, decide to unilaterally terminate my program - with no refund. I am taking a full responsibility for my health choices during my detox program & stay at the Health Oasis Resort. I release Health Oasis Resort from any health or legal responsibility or liability in regards to any health reactions or effects that I may experience during the detox program and after it. I accept these conditions by ticking the following box. I will also sign the copy of this document when I arrive upon my program orientation, before commencing my program I Accept *: Yes Send