Soham - Immersive Healing Program
Registration form cum case record
Select Date
*
1st October - 14th October 2023
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
*
English Proficiency
*
Yes
No
Select Accommodation
As per selection on Booking website
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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
Should be Empty: