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Guest Health Questionnaire
Medical History
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* Indicates required question
Email
*
Your email
First Name
*
Your answer
Middle Name
*
Your answer
Last Name
*
Your answer
Check-In Date
MM
/
DD
/
YYYY
Check-Out Date
MM
/
DD
/
YYYY
Length of Stay (in Day/s)
Your answer
Length of Stay (in Night/s)
*
Your answer
Phone Number
*
Your answer
E-mail Address
*
Your answer
Ethnic Origin
*
Your answer
Blood Type
*
Your answer
Known allergy to food/medication, if any
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Age
*
Your answer
Weight (kg)
*
Your answer
Height (cm)
*
Your answer
Gender
*
Male
Female
Other:
Civil Status
Your answer
Spiritual Orientation / Religion
Your answer
Nationality
Your answer
Country of Domicile
*
Your answer
Cigna International Health Insurance ID Number
* If applicable
Your answer
Treatment Goal.
What do you want to achieve from your stay here at The Farm?
*
Check all that apply. Please prioritize according to the length of your stay.
Break bad habits
Deep cleansing
Detoxification
Fertility
Improve circulation
Improve immunity
Mental health
Muscle relaxation
Pain management
Rejuvenation
Weight management
Sleep recovery
Other:
Required
Medical History
*
Check all that apply
Asthma
Cancer
Cardiac Disease
Diabetes
Hypertension
Psychiatric Disorder
Epilepsy
None
Other:
Required
Kindly list medications utilized in the past six (6) months. Please include vitamins and dietary supplements:
Your answer
Are you allergic, intolerant, or have restrictions to any of the following food items:
Wheat (Gluten)
Milk (Dairy)
Spicy Food
Sour Food
Caffeine
Coffee
Chamomile
Soy
Mushroom
Sesame
Egg
Chicken
Fish
Shellfish
Nuts (Please specify below)
Other:
Please specify nut restriction:
Your answer
Please provide information regarding any other known restrictions (drugs, vitamins, herbs & food) that you may have:
Your answer
Have you undergone surgery in the last 2 years?
If yes, please specify.
*
Your answer
Do you use or do you have a history of using tobacco/cigarette?
If yes, please quantify e.g., sticks per/day x number of years.
*
Your answer
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
For spa considerations, is your skin allergic to coconut oil?
*
Yes
No
Foreign countries/provinces/cities you have worked, visited, transitioned, or traveled to in the past 14 days:
*
Your answer
Are there any other concerns or information that you wish to add that may assist us in maximizing your stay at The Farm?
Your answer
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