Health History – Amrit Ocean Resort

Wellness Survey

All of your information will remain confidential between you and the Health Coach.

All fields are mandatory. For fields you are not certain of, please type N/A.

Personal Information

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?

Other (please specify):

6. Select Gender

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?:

11. What is your occupation?:

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

13. Do you have any kids?:

14. Pets:

Other (please specify):

15. What is your weight?:

16. And what is your height?:

17. Would you like your weight to be different?

18. What foods did you eat often as a child?

a. for breakfast:

b. for lunch:

c. for dinner:

d. as snack:

e. as drinks:

19. Do you currently follow any particular diets?

please specify?

20. What is your food like on a typical day this week?

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?

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.)?

34. What kinds of mindfulness exercise do you engage in regularly?

please specify?

35. In a typical week, how many days do you engage in physical exercises?

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

37. What type of spa services are you most interested in enjoying at Amrit?

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?:

Wellness Survey

All of your information will remain confidential between you and the Health Coach.

All fields are mandatory. For fields you are not certain of, please type N/A.

Personal Information

Meeting Information

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