Next Retreat: Jun 12 - Jun 16, 2023 Hunter Valley
info@sozohealth.com.au

Pre-arrival Health Questionnaire​

Pre-Arrival Health Questionnaire – Expired

  • Program Date: November 2019
    Please rate your current physical health status:
    Please rate your current energy level:
    Please rate your current mental health status:
  • Please list your current health issues in order of priority and rank their severity (mild | moderate | severe).
  • Please select all that apply to you.
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    Do you have a history of cancer, including the presence of a tumor (benign or malignant)?
  • Please list your history of surgeries, from oldest to most recent (include year of surgery).
  • Please list any allergies that you may have.
  • If there is other pertinent health information that you would like us to be aware of, please list that here.
  • Please specify all dietary choices/restrictions that apply to you.
  • Do you exercise regularly? If no, please write NO in the box. If yes, please specify TYPE and DURATION of exercise.
  • Please specify average hours of sleep / night.
  • Please specify what time you normally go to bed (most often) and your wake-up time (most often).
  • How many drinks do you have per week? Please specify and indicate what type of alcoholic beverage your amounts apply to. Example: Beer (cans/bottles) ______ (#) Wine (glasses) ______ (#) Spirits (shots) _______ (#)
  • What is your daily coffee intake amount, on average? Please specify. Example: _______ cups / _________ espressos. Please list other caffeinated beverages that you drink and how often and in what quantity.
  • Please list your daily water intake in terms of cups. Example: 5 cups.
  • Do you currently smoke? If yes, please write YES in the box provided. Please specify how many cigarettes / day. If no, please write NO in the box.
  • Please list all medications and supplements that you currently take, your dosage, frequency taken, and how long you have been using each. Example: Aspirin, 2 pills daily, since June, 2015.
  • Please list the name and a contact number/e-mail of your General Practitioner (GP) and the clinic you visit.