Contact Details Full name: Email address: Phone number: Age, gender: Postal address: Work, role, family, social: What is your role at work? How many hours do you work? Do you do night shifts? How often?
How many are in your family? Describe your role in your family: Describe your social life: Write down five topics/things/events that you find hard to deal with, at work and in other areas of life, currently: How are you dealing with them?
Health information What were the initial signs? When did you notice the signs? When did you get diagnosed? What was your exact diagnosis? Attach your medical document: Attach your medical document:
Health What are other diagnosed conditions you have? When? Symptoms? Medications? Treatments? What are the undiagnosed conditions you have? When? Symptoms? Medications? Treatments? How often does your sleep get disturbed, and why?
Treatment and Diet What are the medications you are on currently? What is the diet you are on currently? What are the new lifestyle activities you have adapted? What are the results? What was your yesterday's breakfast, lunch, dinner, snacks and drinks in detail: How many soft drinks do you have, daily? Do you have any food cravings? How often? What do you eat? How much sugar do you have daily? Do you need extra spice? Do you need extra salt? Do you need extra sugar?
Digestion How do you feel when a meal is delayed? Headache, Irritable/Angry, Acidic, Heavy, Light, Heartburn or Better. How often do you move your bowel? Does it happen at the same time of the day? Is it formed, soft, watery? Does it smell strong, medium, light? How many times do you move your bowel per day? How many times do you urinate per day?
Fitness How many naps (short sleep) or rests do you need daily during the daytime? How many hours of exercise do you do per week? What type of exercises and duration of each of them? When (morning, evening etc) do you do your exercises mostly? How long do you sweat during your exercises? How many times can you do an average block of stairs (going up and down) in 10 minutes? How do you feel after that?
Aptitude Do you think you need to boost your overall health? Why are you interested in our RD2 program? Are you interested in upgrading your health and wellness to a more effective lifestyle? Are you in a position to upgrade to adopt a more effective lifestyle? What sort of moral support you might get from your family, with your wellness program, during and after this retreat? What type? Which areas? How long?
General What is your energy level, out of 10? How long do you sleep? How do you feel when you wake up? Are you generally improving, getting worse, or going steadily with your health? Do you know ours is a natural health retreat? Have you had any health issues that required immediate hospital visit? Are you doing it at your will? Attachment any documents on your: 1) diet, 2) herbs, supplements, 3) natural medications, 4) allopathic medications, and 5) treatments: Do you snore? Any photograph of the affected area if applies?
Important Do you know that the nearest emergency hospital is 60 minutes away? Once we receive it, we'll respond in 48 hours. Your goals General: Specific: Anything else:
