HEALTH AND WELLNESS QUESTIONARE

ALL INFORMATION WRITTEN ON THIS FORM WILL BE KEPT STRICTY CONFIDENTIAL

PERSONAL INFORMATION
Name*
Villa number
Retreat Package
Weight (kg)*
Height (cm)*
Date of birth
DD dot MM dot YYYY
Gender
- Male
- Female
GENERAL HEALTH & WELLNESS
HEALTH CONDITION
Health Goals:
Current Medical Condition
- Diabetes
- Hypertension
- Heart condition
- Others
Other Current Medical Condition
Current medication and supplements:
Past medical condition or operation:
Allergy:
CURRENT CONDITION - HEALTH ISSUES
Physical Issue
Physical Issue No. Detail
Musculo-Skeletal:
- Tightness
- Pain
- Stiffness in joints or muscles
- Crack sounds
- Others
Other Musculo-Skeletal:
Brain/Neurological:
- Headache
- Dizziness
- Brain fog
- Forgetfulness
- Weakness/Numbness/Tingling
- Others
Other Brain/Neurological:
Respiratory:
- Difficulty breathing
- Shortness of breath
- Chest tightness
- Others
Other Respiratory:
Cardiovascular:
- Irregular heartbeat
- High/low blood pressure
- Sensitivity to hot or cold
- Others
Other Cardiovascular:
Digestive System:
- Heart burn
- Nausea
- Indigestion
- Bloating
- Stomach cramp
- Hemorrhoid
- Constipation
- Diarrhea mucus or blood in stools
- Others
Other Digestive System:
Skin:
- Acne
- Easily developing scar or Keloid
- Wrinkle
- Rash
- Skin allergy/sensitivity
- Dry skin
- Oily skin
- Others
Other Skin:
Immune Systems:
- Recurrent infection
- Frequent cold & flu
- Hay fever
- Hives
- Others
Other Immune Systems:
REPRODUCTIVE-URINARY SYSTEM
Are You Pregnant:
- Yes
- No
Months
Do You Have Regular / Gynecological Exams/Mammograms:
- Yes
- No
Do You Have A History With Any Of The Following:
- Menstrual issues
- Menopause
- Thrush
- Urinary tract infections
- Prostate
- Urination
- Sexually transmitted diseases
- Others
Other Do You Have A History With Any Of The Following:
LIFESTYLES
SLEEP
Sleep Pattern (Hour Per Night)
Please enter a number from 0 to 24.
Bed Time
Wake Up Time
Sleep Problem:
- Difficult to sleep
- Wake up at night
- Nightmare
- Others
Other Sleep Problem:
PHYSICAL ACTIVITY & EXCERCISE
Exercise (Times Per Week)
Please enter a number from 0 to 24.
TYPE OF EXERCISE/ACTIVITY
DIET
Diet Preference:
- Vegan
- Vegetarian
- Keto
- Paleo
- Others
Other Diet Preference:
DRINKING
How many alcohol per day ?
How many cups of coffee per day ?
How many cups of tea per day ?
How many glasses of water per day ?
How many glasses of soft drink per day ?
Other Drinking:
Avoiding Food & Drink
Smoking
- Yes
- No
How many cigarette per day ?
MIND & EMOTIONAL OVERVIEW
Stress levels scale of 1 to 10 (1 = low; 10 = high)
Emotional, Imbalance:
- Anger
- Frustration
- Sadness
- Worry
- Fear
- Aggression
- Impatience
- Anxiety
- Depression
- Others
Other Emotional, Imbalance:
OTHERS
Do you get claustrophobic and so, In what situation ?
Other: Do you have or use any of the following: Contacts / Glasses, Pacemaker, Prosthesis, Metal pins ,Implants, Hearing, AID, IUD
We recommend you bring the following items with you, to help make the most of your RAKxa experience:
1. Any relevant blood tests, X-rays or other medical reports
2. Comfortable shoes for walking/training shoes
3. Comfortable sports clothes
4. Swim wear
I hereby consent to the use if my personal information (including any sensitive data) for the purpose of my treatment and confirm that any of these is at my own risk without limiting or affecting any statutory rights I may have. I agree that any dispute or claim that arises out of, or is related to such treatment and/or service shall be subject to the law and the exclusive jurisdiction of the courts of the country/region in which the relevant treatment and/or service takes place.
Date
DD dot MM dot YYYY
Guest's signature
Only for RAKxa Team Members
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Name
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Physical Issue No.	Detail

HEALTH AND WELLNESS QUESTIONARE

ALL INFORMATION WRITTEN ON THIS FORM WILL BE KEPT STRICTY CONFIDENTIAL

PERSONAL INFORMATION

GENERAL HEALTH & WELLNESS

CURRENT CONDITION - HEALTH ISSUES

REPRODUCTIVE-URINARY SYSTEM

LIFESTYLES

PHYSICAL ACTIVITY & EXCERCISE

DIET

DRINKING

OTHERS

We recommend you bring the following items with you, to help make the most of your RAKxa experience:

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