Personal Details Name* First Last Title*MrMsDate of Birth* Date Format: DD dash MM dash YYYY Contact Number **Email ** Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AustraliaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Arrival Date* Date Format: DD dash MM dash YYYY Are you celebrating a special occasion?*YesNoUntitledDo you have any particular dietary requirement ?*YesNoUntitled Do you have symptoms of COVID-19? Symptoms of COVID-19 can range from mild illness to pneumonia. Some people will recover easily, and others may get very sick very quickly. The common symptoms of COVID-19 may include: fever coughing sore throat Loss of taste or smell fatigue (tiredness), and difficulty breathing or shortness of breath. If you have any symptoms or have been in contact with someone who has a COVID-19 diagnosis, please contact us right away so that we can discuss your bookingHolistic activities Stretching Pilates Yoga Qi gong Others Improvements Fitness Ideal Weight GUT health Sleep Enhancement Intro to Detox Comprehensive Detox Lifestyle Change Other Personal Health QuestionnaireUntitledPlease indicate if any of the following apply to you. High Blood pressure Low blood pressure Diabetes Heart condition Epilepsy Cancer Hepatitis/HIV/infectious disease Pregnant other Medical condition or troublesome symptomsYesNoMedical condition or troublesome symptomsRecently occurring symptoms or illness*YesNoRecently occurring symptoms or illnessAre you taking any Medications ?*YesNoMedications being taken.Are you taking any Vitamins ?*YesNoVitamins/mineral supplements being takenDo you have any allergies ?*YesNoDetails of allergies.Recent major Illness or surgery ?*YesNoProvide detailsAny implants, metal pins or plates, hearing aid or pacemaker ?*YesNoProvide detailsNutritional Status / RequirementsWould you like advice on improving dietary habits ?*YesNoDo you smoke ?*YesNoSamadhi is strictly a non smoking and non vaping environment. Guest who smoke will need to exit the building and walk up into the car park if they need to smoke.Any food allergies or food sensitivities?*YesNoSamadhi makes every attempt to identify ingredients that may cause an allergic reactions for those with food allergies. However there is always risk of contamination as in our kitchen we use products such as milk, eggs, gluten, seafood, peanuts, other nuts, sesame seeds and capsicum, although we have strict cross contamination policies; we can not guarantee a total absence of these products in any of our cuisine. Guests with food allergies must be aware of this risk. Sleep and EnergyDo you exercise frequently ?*YesNoDo you sleep well ?*YesNoUntitledGeneral Stress and TensionDo you feel highly stressed ?*YesNoUntitledRate your Stress Level from 1 -1012345678910Do you regularly partake in any stress reducing activities ?*YesNoDo you have any special requirements pertaining to your health and wellbeing?*YesNoAt Samadhi, we are committed to safeguarding your privacy. Prior to submitting the form, please take some time to read our Privacy Policy and make sure you are happy with our use and storage of your personal information.Privacy Policy* Yes, I have read and accepted the privacy policy. CAPTCHA
