fields marked in red are required 
 

The following brief questionnaire is mostly to gauge how we can best accommodate you and your needs.
It's not not a 'pass or fail' type of thing, as we strive to assist whomever comes along.  We also won't 'judge'
a person based on responses, as we acknowledge that each person has their own set of unique circumstances
which brought them to this stage of seeking to improve their condition.  Each interested person
should fill out their own form.   All info herein will be kept confidential - we value your privacy.

A..   Main reasons for wanting to visit our facilities in Chiang Rai:    

Check as many as apply:    

  Clean out the body                  De-toxify               Lose weight                 

   Tone up muscles and form                 Lose or lessen one or more addictions 

  Help out at the Farm                    Just relax

  Explore Chiang Rai as a place to settle               Explore Chiang Rai as a visitor           

  Other [specify briefly below]

B.    Briefly describe your body type.   Check as many as apply:

about right for my height.       a bit overweight,           considerably overweight,          get stuck in door frames

underweight                 Other, articulate briefly: 

If you checked 'overweight,' would you say you have mostly   'hard fat' [beer gut]       or    'soft fat' [plump]       mix

C.   Eating and Drinking.   Check as many as apply to you:  

eat robustly, like a Roman Centurian - everything including red meat, and every sauce on the menu.     

overindulge in greasy salty snacks and soda pop.

eat mostly moderate, but some indulgences                         healthy, restrictive diet               

Strict, or other type of diet [specify]   

D.  Habits and Addictions.    Check as many as apply:  

Drink alcoholic drinks:      none             little bit          moderate         lots            sauced & pickled

Smoke tobacco:         none             a bit          moderate         lots            like a chimney

Coffee:        none             little bit           moderate           got to have it each morning            day and evening

Other addictions that you're aware of or suspect [specify briefly]:   

E.    Medical conditions.    Check as many as apply, or leave blank in they don't apply:  

Have you been diagnosed as having any physical ailments?  [specify briefly]   

Have you been diagnosed with a mental condition?  [specify]   

Any drugs that you're required to take: [specify briefly]   

Do you suspect you may have other ailments which have not yet been diagnosed?
[specify briefly]   

Do you lean more to alternative medicine, or to  medicines prescribed by hospitals and clinics?   or   either are ok.
 

F.  Briefly describe which of the following things you've had done within the past three years for your body's health.
Check as many as apply:

skip a meal once in awhile          did a 24 hour fast       
fasted for more than a day [describe]   

Have you ever had an enema?       yes      no                        If so, could you self-administer an enema?    yes     no 

Have you ever had a colonic irrigation?      yes      no              If so, was the colonic a one-time deal, or a series

Note: if you don't know the terms 'enema' or 'colonic irrigation,' then that's ok - you can skip this section.

F.  Briefly describe which of the following things you've had done within the past three years for your body's health.
Check as many as apply:

skip a meal once in awhile          did a 24 hour fast       
fasted for more than a day [describe]   

Have you ever had an enema?       yes      no                        If so, could you self-administer an enema?    yes     no 

Have you ever had a colonic irrigation?      yes      no              If so, was the colonic a one-time deal, or a series

Note: if you don't know the terms 'enema' or 'colonic irrigation,' then that's ok - you can skip this section.

Added comments about anything related to this form:  

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