CONFIDENTIAL HEALTH QUESTIONNAIRE: 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Email * Sex* Select Male Female Age Group* Select 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-80 Weight* Select 41 kg - 90 lbs 42 kg - 92 lbs 43 kg - 95 lbs 44 kg - 97 lbs 45 kg - 99 lbs 46 kg - 101 lbs 47 kg - 104 lbs 48 kg - 106 lbs 49 kg - 108 lbs 50 kg - 110 lbs 51 kg - 112 lbs 52 kg - 115 lbs 53 kg - 117 lbs 54 kg - 119 lbs 55 kg - 121 lbs 56 kg - 123 lbs 57 kg - 126 lbs 58 kg - 128 lbs 59 kg - 130 lbs 60 kg - 132 lbs 61 kg - 134 lbs 62 kg - 137 lbs 63 kg - 139 lbs 64 kg - 141 lbs 65 kg - 143 lbs 66 kg - 145 lbs 67 kg - 148 lbs 68 kg - 150 lbs 69 kg - 152 lbs 70 kg - 154 lbs 71 kg - 157 lbs 72 kg - 159 lbs 73 kg - 161 lbs 74 kg - 163 lbs 75 kg - 165 lbs 76 kg - 168 lbs 77 kg - 170 lbs 78 kg - 172 lbs 79 kg - 174 lbs 80 kg - 176 lbs 81 kg - 179 lbs 82 kg - 181 lbs 83 kg - 183 lbs 84 kg - 185 lbs 85 kg - 187 lbs 86 kg - 190 lbs 87 kg - 192 lbs 88 kg - 194 lbs 89 kg - 196 lbs 90 kg - 198 lbs 91 kg - 201 lbs 92 kg - 203 lbs 93 kg - 205 lbs 94 kg - 207 lbs 95 kg - 209 lbs 96 kg - 212 lbs 97 kg - 214 lbs 98 kg - 216 lbs 99 kg - 218 lbs 100 kg - 220 lbs 101 kg - 223 lbs 102 kg - 225 lbs 103 kg - 227 lbs 104 kg - 229 lbs 105 kg - 231 lbs 106 kg - 234 lbs 107 kg - 236 lbs 108 kg - 238 lbs 109 kg - 240 lbs 110 kg - 243 lbs 111 kg - 245 lbs 112 kg - 247 lbs 113 kg - 249 lbs 114 kg - 251 lbs 115 kg - 254 lbs 116 kg - 256 lbs 117 kg - 258 lbs 118 kg - 260 lbs 119 kg - 262 lbs 120 kg - 265 lbs 121 kg - 267 lbs 122 kg - 269 lbs 123 kg - 271 lbs 124 kg - 273 lbs 125 kg - 276 lbs 126 kg - 278 lbs 127 kg - 280 lbs 128 kg - 282 lbs 129 kg - 284 lbs 130 kg - 287 lbs 131 kg - 289 lbs 132 kg - 291 lbs 133 kg - 293 lbs 134 kg - 295 lbs 135 kg - 298 lbs 136 kg - 300 lbs 137 kg - 302 lbs 138 kg - 304 lbs 139 kg - 306 lbs 140 kg - 309 lbs 141 kg - 311 lbs 142 kg - 313 lbs 143 kg - 315 lbs 144 kg - 317 lbs 145 kg - 320 lbs 146 kg - 322 lbs 147 kg - 324 lbs 148 kg - 326 lbs 149 kg - 328 lbs 150 kg - 331 lbs 151 kg - 333 lbs 152 kg - 335 lbs 153 kg - 337 lbs 154 kg - 340 lbs 155 kg - 342 lbs 156 kg - 344 lbs 157 kg - 346 lbs 158 kg - 348 lbs 159 kg - 351 lbs 160 kg - 353 lbs Height* Select 142cm- 4 ft 8 in 4 ft 9 in 147cm - 4 ft 10 in 150cm - 4 ft 11 in 152cm - 5 ft 0 in 155cm - 5 ft 1 in 157cm - 5 ft 2 in 160cm - 5 ft 3 in 163cm - 5 ft 4 in 165cm - 5 ft 5 in 168cm - 5 ft 6 in 170cm - 5 ft 7 in 173cm - 5 ft 8 in 175cm - 5 ft 9 in 178cm - 5 ft 10 in 180cm - 5 ft 11 in 183cm - 6 ft 0 in 185cm - 6 ft 1 in 188cm - 6 ft 2 in 191cm - 6 ft 3 in 193cm - 6 ft 4 in 196cm - 6 ft 5 in 198cm - 6 ft 6 in 200cm - 6 ft 7 in BMI* Select <18.5 18.5 - 25 25 - 30 >30 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