H R H the Duchess of
H R H the Duke of
H R H The Princess
HE The French Ambassador M
His Hon Judge
HRH Sultan Shah
HRH The Prince
HRH The Princess
HSH The Prince
Lord and Lady
Mr and Mrs
Mr and The Hon Mrs
Rt Hon Baroness
Rt Hon Lord
Rt Hon Sir
Rt Hon The Earl
Rt Hon Viscount
The Countess of
The Dowager Marchioness of
The Duchess of
The Duke of
The Earl of
The Hon Mr
The Hon Mrs
The Hon Ms
The Hon Sir
The Marchioness of
The Rt Hon
The Rt Hon Lord
The Rt Hon Sir
The Rt Hon The Lord
The Rt Hon the Viscount
The Rt Hon Viscount
The Very Rev Dr
Viscount and Viscountess
Arctic (Siberian, Eskimo)
Caucasian (Middle East)
Caucasian (North African, Other)
North East Asian (Mongol, Tibetan, etc)
Pacific (Polynesian, Micronesian, etc)
South East Asian (Thai, Malay, Filipino, etc)
West African, Bushmen, Ethiopian
1. Please underline/highlight the statement that BEST describes the intentions of your stay:
I just want to relax, be cared for and left alone. I want my peace and quiet.
I am interested in taking the necessary steps to achieve a healthier life.
I have issues and/or “diseases” that are having a negative impact on my health and quality of life. I am seeking help to correct the issues and reverse my “disease/s.”
I want to experience everything that the FARM has to offer.
2. Please, indicate your main health concern, if any.
2.1 What are your goals for your stay at the Farm?
4. Please list medications utilized during the course of the past six (6) months. Please, include vitamins and dietary supplements.
5. Have you undergone abdominal surgery or other surgery in the last 2 years? If yes, please indicate the reason for the surgery and the date the surgery was performed.
6. Have you had colon hydrotherapy or other colon cleansing treatment before? If yes, please indicate the date, the name of the institution and the country
7. Please, indicate the MAXIMUM duration you are able to allow for you stay:
(The Medical Doctors will prescribe the duration of the program on the basis of your state of health and the health goals you have defined, as well as allowable time away from work and family)
9. Do you smoke cigarettes, cigars? How frequent? How many sticks/ packs per day?
10. Do you drink alcoholic beverages? What kind (beer, wine, gin, whisky, brandy) and how frequent per week?
11. Do you make use of recreational drugs? If yes, please, provide information about the type of substance, amount consumed and the duration of usage.
12. How many meals and snacks do you eat per day?
13. How often do you eat the following in a week?
14. Please list your current stressors at
15. Are there any other concerns or information that you wish to add that may facilitate us to maximize your stay at the Farm?
16. The Farm at San Benito offers a wide variety of services as well as provides private sessions. Please underline/highlight any areas that are of interest to you during your stay:
Integrative Medicine (consultation, Digital Meridian scan, Nutritional Microscopy)
Body Treatments (massages, body scrubs, herbal wraps, etc.)
Detoxification (colon hydrotherapies, wheatgrass infusion, liver cleanse, etc.)
Exercise/Movement (yoga, personal training, power walk, etc.)
Healing Energy (acupuncture, Reiki, craniosacral therapy, etc.)
Metaphysical Services (intuitive counseling, tarot card readings, etc.)
Food (consultations with a nutritionist, lab evaluations, Genomics, menu design, healthy weight, etc.)
Outdoor activities (Golf, fishing, etc.)
Kids & Teen Services (for guests ages less than 17)
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