Title Mr Mrs Ms Miss Advocate Ambassador Baron Baroness Brigadier Brigadier Canon Captain Chancellor Chief Col Comdr Commodore Councillor Count Countess Dame Dr Duke of Earl Earl of Father General Group Captain H R H the Duchess of H R H the Duke of H R H The Princess HE Mr HE Senora HE The French Ambassador M Her Excellency Her Highness His Excellency His Highness His Hon His Hon Judge Hon Hon Ambassador Hon Dr Hon Lady Hon Mrs HRH HRH Sultan Shah HRH The HRH The Prince HRH The Princess HSH Princess HSH The Prince Judge King Lady Lord Lord and Lady Lord Justice Lt Cdr Lt Col Madam Madame Maj Maj Gen Major Marchesa Marchese Marchioness Marchioness of Marquess Marquess of Marquis Marquise Master Minister Mr and Mrs Mr and The Hon Mrs Mx Pope President Prince Princess Princessin Prof Prof Emeritus Prof Dame Professor Queen Rabbi Representative Rev Canon Rev Dr Rev Mgr Rev Preb Reverend Reverend Father Right Rev Rt Hon Rt Hon Baroness Rt Hon Lord Rt Hon Sir Rt Hon The Earl Rt Hon Viscount Senator Sir Sister Sultan The Baroness The Countess The Countess of The Dowager Marchioness of The Duchess The Duchess of The Duke of The Earl of The Hon The Hon Mr The Hon Mrs The Hon Ms The Hon Sir The Lady The Lord The Marchioness of The Princess The Reverend 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 Venerable The Very Rev Dr Very Reverend Viscondessa Viscount Viscount and Viscountess Viscountess W Baron W/Cdr
Ethnic Origin Mixed Race Arctic (Siberian, Eskimo) Caucasian (European) Caucasian (Indian) Caucasian (Middle East) Caucasian (North African, Other) Indigenous Australian Native American North East Asian (Mongol, Tibetan, etc) Korean Japanese Pacific (Polynesian, Micronesian, etc) Chinese South East Asian (Thai, Malay, Filipino, etc) West African, Bushmen, Ethiopian Other Race
Civil Status Single Married Separated Divorced Widowed
Gender Male Female Questions 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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