Phone: 07 5499 9244

Medical Questionnaire

Guest Information Details Questionnaire
Important – To Be Returned ASAP before Arrival

Confidentiality
Palladium Private hosted at Fountainhead Retreat is committed to the health and safety of its guests. As part of these commitments, this Medical History Questionnaire is required to be completed by guests prior to arrival. The completed form will only be seen by certain staff members where necessary and is used to guide us about how to assist you as quickly as possible so please be truthful and accurate. If  you are  in need of immediate medical attention  the below details will be given to the appropriate medical officer.

Name:

Date Of Birth:

Phone:

Email:

Address:

Postal Address:
 
Emergency Contact Name:

Relationship to Emergency Contact:

Emergency Contact Phone:

Emergency Contact Address:
 
Age:

Height (CM):

Weight

Martial Status:

Children:
Yes No 
Doctors Name:

Doctors Clinic Name:

Doctors Contact Phone:

Doctors Contact Address:
 
Are you seeing any Health Specialists? For what treatment?:

Specialist's Name:

Specialist's Clinic Name:

Specialist's Phone:

Specialist's Address:
 
Occupation:

Any Injuries / Illnesses due from your occupation:

Present Health Concerns:

How Long has this been a problem?:

Allergies:

Are you pregnant or do you think you might be?

Do you have any Phobias/Fears?:

Do you or have you ever had an eating disorder?

How long has this been an issue?

Yes/No Please give details where appropriate
Are you presently on any medication or treatment prescribed by a doctor?

What quantity do you take on a daily basis?

Are You a Smoker? If So Please give details:

Do You Drink Alcohol? if so how many units per week?
(NB 1 unit is 1/2 pint of beer or 1 medium glass of wine)

Do you drink coffee or other caffeine based drinks? if so how much?

Do you exercise? if so how often?

How much water do you drink per day?

Have you ever water or juice fasted?

Have you attended any other detox programme?

Have you been on any weight loss programmes?

How committed are you to completing a program?

Are there any areas of your programme you are not currently sure about?

Please describe your nutrition on an average day
Morning:

Mid Morning

Lunch

Mid afternoon

Dinner

After Dinner

Have you ever suffered from any of the following illnesses?
Yes / No. if yes, please give details in provided section beneath:

Cancer:

Heart disease, high blood pressure:

Visual defects/ eye conditions (including colour blindness):

Paralysis or other neurological disorder:

Liver Disorder:

Kidney Problem:

Recurrent headaches, migraine:

Vertigo, giddiness or tinnitus:

Hearing defects/ear conditions:

Asthma, brochitis, tuberculosis or other chest disease:

Chest Pains / breathing problems:

Palpitations:

Pneumonia:

Sinus / Nose Problem:

Throat Problem:

Recurrent backache/ neck ache, arthritis,
rheumatism, Muscle spasms / Cramps:

Easy Bruising:

Eczema, dermatitis, sensitive skin,
other skin conditions:

Diabetes, thyroid or other gland problems:

Kidney or bladder problems:

Peptic ulcer, Diarrhoea, Constitpation,
or other digestive/ intestinal/ bowel disorder:

Blood in Stool:

Haemorrhoids:

Tuberculosis:

Ross River Fever, Glandular Fever,
Swollen glans/ joints

Chicken Pox, Mumps:

Colitis:
 Tumour, Cyst:

Depression - Clinical Bipolar, Post Natal, Severe Anxiety,
Excessive Worry, Panic Attacks, Nervousness:

Loss/ Gain of Weight:

Eating Disorders:

High Cholesterole:

Hernia:

Urinary Problems:

Gall Stones / Gall Bladder Problems:

Consistent Gas or Bloating:

Fainting Attacks, Blackouts, epilepsy or fits:

Varicose veins causing trouble:

Clot in veins:

Jaundice:

Any blood disorder, anaemia, High / Low Blood pressure:

AIDS / HIV:

Any impairment of immunity to infection/
Any recurrent infections:

Veneral Disease:

Gum or tooth problems:

Hayfever, allergies to drugs, animals etc:

Sexual Dysfunction:

Prostate, Testicle Problems:

Pregnancy difficulties:

Breast Problems:

Gynaecological Problems:

Birth Control Pills:

Any alcohol or drug related problems or illness:

Any other Medical condition, physical or mental
not mentioned above:(Required Field)

Notes:



General Information

Please use this area below to explain in detail the health concerns you have & what you have previously done for them, effective or not?

What are your goals for this retreat?

what are your major life goals at the moment?

What are your three best virtues?


What don't you like about you?

What did your parents teach you that you will / did pass to your children?

What is your golden rule?

What are the issues that you think really cause your stress?

Please discuss your sleeping patterns (Time to bed, time up, total hours sleep, quality of sleep):

Please discuss your level of comfort with yourself in regard to:
Success:

Financial Security:

Health:

Spirituality:

Identity:

If your were to die tomorrow, what would be your main regret?

If you were to die tomorrow what would be your proudest achievement?

Declaration:
1. I declare that, to the best of my knowledge, the information I have given in correct.
2. I understand that I may be required to attend a medical examination

Name:
Date: