--- Welcome to Namaste Retreats ---

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Your Information

All fields are required!

Full Name

Contact No

E-mail Address To be used for internal marketing purposes only

Gender

Male Female

Are you pregnant and/or breastfeeding?

Yes No

Weight in Kilograms (Kgs)

Height in Meters (M)

Age

Lifestyle Questions How would you rate your overall health currently?

Excellent Good Average Poor

On average how many prescriptions do you get from the doctor in one year?

None Once Two or more

Do you suffer from headaches, migraines, anxiety or chest pains?

Yes No

Do you suffer from sinus, allergies or regular ear infections?

Yes No

Do you get pimples, acne or rashes?

Yes No

Do you find it difficult to loose weight?

Yes No

Is your tongue furry or coated with a white mucous layer?

Yes No

Do you often feel bloated, or have puffy hands, ankles or feet?

Yes No

Are you often feeling tired, unwell or nauseous?

Yes No

Do you have dark circles under your eyes?

Yes No

Do you sweat allot and have a strong body odour?

Yes No

Would you describe your-self as stressed-out or depressed?

Yes No

Do you get constipated regularly?

Yes No

Do you get out of breath easily?

Yes No

Do your hands and feet often get cold?

Yes No

Is your concentration or memory poorer than it used to be?

Yes No

Do you rely on stimulants (e.g. coffee) to keep you going through the day?

Yes No

Do you often crave sweet foods?

Yes No

Do you have weak brittle or cracked nails?

Yes No

Do you get less than 6 hours sleep a night?

Yes No

Your Feedback

Please complete the forms to receive your health feedback.

Note to user:

Pregnant, or breast feeding women as well as people under 18 are advised to select the Revitalise Programme only.

Should you have any diagnosed illness, additictions or you are over the age of 65 we recommend that you seek medical approval.

Please note that this test gives only an indication of your present overall physical health and is not to be used as medical advice.

The body mass index (BMI) is a measurement tool which is utilised to compare a person's weight to their height. Though it does not actually measure the percentage of body fat, it can be used as an estimation of a healthy body weight.