Health Check Form

Health Check Form. The following information will be treated with strict confidence and is required for your safety and to benefit your health. There may be certain contraindications, which will require special attention and/or further discussion. It may be necessary to consult with your Medical Practitioners before the start of any of our retreat or online detox and wellness programs. Take your time to fill out this health Questionnaire with complete honesty, a thorough health screening can help us to personally tailor together the most efficient retreat or online wellness program. 

Fill out the online Health Check Form so we can give you the best guidance possible. The health check is free when you book your program. Charge is 3,000 THB (96 USD, 72 GBP, 81 EUR, 132 AUD, 352 AED), please check latest currency updates. For more information about our online programs go to Programs 

Thank you for reaching out to us and we will get back to you shortly!

Health Check Form

Request the health check form

If you have any questions about the Health Check Form you can go to our blog and read up about the body systems and disorders or contact us: [email protected] or call Patrick directly at +66 (0) 844408853 Thailand, Koh Samui.

Systolic / Diastolic / Pulse Rate
Systolic / Diastolic / Pulse Rate
Normal readings Celcius 36.55 to 36.77 - Fahrenheit 97.8 - 98.2
Numbers of times in 1 minute
Please list all concerns for each family member. leave blank if you aren't sure.
Please list all surgical procedures injuries, minor or major, and year.
Quote Times and Dosages
Quote Times and Dosages
Be honest, note that your diet over the last 3 months has a strong impact on how you feel today.
Be honest, note that your diet over the last 3 months has a strong impact on how you feel today.
Be honest, note that your diet over the last 3 months has a strong impact on how you feel today.
Be honest, note that your diet over the last 3 months has a strong impact on how you feel today.
Be honest, note that your diet over the last 3 months has a strong impact on how you feel today.
Note that your diet over the last 3 months has a strong impact on how you feel today.
I have symptoms of Depression, Post Traumatic Stress Disorder, Obsessive-Compulsive Disorder, etc... please list.
Divorce, separation, lost job, bankruptcy, etc...please list.
Arthritis, Osteoarthritis, Bursitis. etc.. Please List
If yes, where any other organs removed? Lymph nodes removed? Please list which?
Period since? For how long?
How often do you urinate?
What are your PSA levels
I have 0-1,2,3,+4 bowel movements
I have 0-1,2,3,+4 meals
Please List
List which areas of the body
How many Lymph nodes were removed? Where?
Please Provide location(s)
Please Provide location
Please Provide location of Non-Maligent Mass/Tumore
List which areas of the body
How many treatments of Chemo or radiation? Year?
Please list which ones
This information is confidential and used to help you attain optimal health only.
Are you interested in doing other studies? If yes, which ones?