Health Consultation Form

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Retreat Guru is the online booking agent for Samadi Healing.

* These fields are required

1 Welcome

2 Price

3 Personal Details

Birth Date *
Gender *
Nationality
ID number *
Occupation
City / Town / Suburb *
Country *
Discount code

4 Health

5 Medications, Supplements and Drugs

6 Diet

7 Lifestyle

These questions are designed to identify the stressors in your life that may hinder health improvement as well as resources we can utilize to aid it.

How would you describe your sleep patterns? (Duration, quality of sleep, number of times you wake during the night and for how long) *
How frequently do you exercise? *	Daily 3 to 5 times a week Weekly Less than once a week
Please list the kinds of exercise you do. *
Are you employed? *	Yes No
If ’yes’ on what basis? *	Full-time Part-time Casual Not applicable
How would you describe your work environment? *	Enjoyable Exciting Neutral Boring Somewhat stressful Extremely stressful Not applicable
How would you describe your home environment? *	Supportive / safe Neutral Somewhat stressful Extremely stressful
Do you have any significant stressors in your life that you haven't already mentioned? (eg. finances, relationships, illness). If so please give brief details i.e date of onset of stressor, severity, frequency, etc. *
Please describe the strategies you use to address these stressors. *	(If not applicable please write ’NA’).
What do you enjoy doing in your leisure time? *
Are you willing and able to incorporate therapeutic practices into your daily routine? *	Yes No
If yes, how much time are you able to devote to such practices? *	10-20 minutes a day 30-45 minutes a day An hour or more
Prior to our consultation, it's helpful for me to get a rough idea of the pace you’d like to work at. Please select one of the following: *	I'm happy to work fast. I'd like to make a lot of changes to my diet and lifestyle in a short period of time. I'm aware the detox may be more severe but I'm willing to stick with it to see results more quickly. I'd like to work at a moderate pace. I'm happy to make 1-2 changes a week and see results in 2-3 months. I'd like to work slowly. I'm aware that old habits can be hard to break and its easier to make small changes over a long period of time. I realize it might take longer to see results, but working in this way is also more likely to ensure the changes I do make will be permanent.

8 Disclaimer

9 Payment