Soham - Immersive Healing Program
Registration form cum case record
Select Date
*
17th January to 31st January 2021
21st February to 7th March 2021
26th September to 10th October 2021
7th November to 21st November 2021
Name
*
First Name
Last Name
Gender
*
Male
Female
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Age
*
Height
*
(in cm)
Weight
*
(KG)
Occupation
*
Select Accommodation
*
Single Standard Room with common bath - Rs. 16,000 for 2 weeks
Single Standard Room with attached bath - Rs. 23,200 for 2 weeks
Single Executive Room (Non-AC) - Rs. 25,600 for 2 weeks
Single Executive Room (AC) - Rs. 30,000 + taxes for 2 weeks
Single Deluxe Room (Non-AC) - Rs. 38,800 + taxes for 2 weeks
Single Deluxe Room (AC) - Rs. 43,200 + taxes for 2 weeks
Back
Next
Lifestyle Information
What is the activity level at your work?
*
Mostly seated
Light movement with intermittent walking
Heavy labour
Do you follow a regular working schedule; do you work days, afternoon or nights?
*
Yes
No
How often do you travel?
*
Rarely
Few times a year
Frequently
Every week
Please mention the physical activities that you participate in:
*
Back
Next
Medical Information
If you have been diagnosed with any health problems, list the condition(s).
*
If you are on any medication, please mention them:
*
Any additional therapies being undertaken for the given health problem(s)?
*
If you have any injuries, please mention them:
*
Do you have any stress or reason for lack of motivation?
*
Yes
No
Have any of your immediate family members developed heart disease before the age of 60?
*
Yes
No
Do any diseases run in your family
*
Yes
No
Do you suffer from diabetes, asthma, high or low blood pressure?
*
Yes
No
If yes, please mention them
Do you smoke?
*
Yes
No
Your current diet could be best categorised as:
*
Low-fat
Low-carb
High Protein
Vegetarian/Vegan
No special diet
*
Submit
Should be Empty: