Soham - Immersive Healing Program
Registration form cum case record
Select Date
*
12th - 26th January 2020
16th February - 1st March 2020
15th - 29th March 2020
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
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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 (AVAILABLE FOR FEB AND MARCH 2020. FULL UP FOR JAN 2020)
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
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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:
*
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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
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