1. First Name:

2. Last Name:

3. Email:

4. Phone No:

5. Do you use any wearable devices to track your daily sleep and activity level?
SelectApple WatchFitbitOura RingWhoop StrapGarminI do not use any wearable deviceOther (Please Specify)

Other (please specify):

6. Select Gender
SelectMaleFemaleNon-binaryPrefer not to answer

Prefer to self-describe:

7. DOB:

8. And where were you born (Country, state, or city)?:

9. Where do you currently live (Country, state, or city)?:

10. What is your relationship status?:—Please choose an option—Married or in a relationshipSeparated or divorcedSinglePrefer not to say

11. What is your occupation?:

12. How many hours do you work in a typical week?:

13. Do you have any kids?:—Please choose an option—yesno

14. Pets:—Please choose an option—NoDog(s)Cat(s)other (please specify)

Other (please specify):

15. What is your weight?:

Choose UnitLbskg

16. And what is your height?:

Choose Unitm/cmft/in

17. Would you like your weight to be different?selectYesNo

a. for breakfast:

b. for lunch:

c. for dinner:

d. as snack:

e. as drinks:

19. Do you currently follow any particular diets? —Please choose an option—VeganVegetarianKetoIntermittent FastingLow CarbLow FatBlood type DietNothing in particularOther

please specify?

a. for breakfast:

b. for lunch:

c. for dinner:

d. as snack:

e. as drinks:

21. Do you experience any digestive issues, such as constipation, diarrhea, or gas?

22. Do you cook?—Please choose an option—YesNo

23. What percentage of your food is home-cooked in a typical week?

24. Where do you get the rest from?

25. Do you crave sugar, coffee, cigarettes? or any other major addictions?

26. Do you have any serious illness, hospitalization, or injuries? Please specify:

27. What is/was the health of your father?

28. What is/was the health of your mother?

29. How is your sleep?

E.g., Do you experience difficulties falling asleep? Do you wake up at night?

30. How many hours do you typically sleep each night?

31. At what point in your life did you feel at your best? Why?

32. What are your main health concerns, if any?

33. In a typical week, how many days do you engage in mindfulness exercises (yoga, meditation, journaling, etc.)?—Please choose an option—1234567

34. What kinds of mindfulness exercise do you engage in regularly?—Please choose an option—YogaMeditationJournalingTachiBreathworkOther (please specify)Nothing in particular

please specify?

35. In a typical week, how many days do you engage in physical exercises?—Please choose an option—1234567

36. Do you take any supplements or medications? Please list

37. What type of spa services are you most interested in enjoying at Amrit?—Please choose an option—MassagesTouchless Technology Treatment (e.g. Cryotherapy, Infrared Sauna)Sound & Light TherapyIntegrative Medicine Treatment (e.g. Ayurveda, TCM, Functional medicine)All of Them

38. Is there any particular day or time you would prefer these services scheduled? or time slots we should avoid while booking your services? Please specify below:

(please be advised that we can only accommodate your preferences based on availability, we will certainly do our best!)

39. Anything else you would like to share?: