Promotion on Weight Loss, Rejuvenation and Transformation Detox programmes
PROGRAMMES
Detox
New You Weight Loss Detox
Vitality Juice Detox Retreat
Raw Food Detox
Inner Beauty & SPA detox
Burnout Detox
Holistic Rejuvenation Detox
Healing
Reiki Training Retreat
Burnout Detox
Holistic Rejuvenation Detox
Detox with Reiki Retreat
Yoga
New You Weight Loss Detox
Yoga Immersion Retreat
Fitness
Fat Burn with Strength and Conditioning
New You Weight Loss Detox
Ultimate Transformation Retreat
Therapies and Courses
Holistic Healing
Spa
Courses & Classes
THE SPACE
Accommodation
Beachfront Resort
Private Villa
Alchemy Café
Retreat Facilities
ABOUT
About Us
Testimonials
Pre-Cleanse
Blog
RESERVATION
CONTACT
Health Questionnaire
Health Questionnaire
Personal Information
Name
First
Last
Arrival Date
Date Format: MM slash DD slash YYYY
Returning Guest
Yes
No
Email
Emergency Contact
*
Name, Contact Details, Country of Residence
Age
Height
Current Weight
Occupation
Relationship Status
Single
Married
Partnered
What is the main reason for you coming to Orion Retreat?
Health History
Have you ever been hospitalised?
Yes
No
If yes, please provide details:
Have you detoxed before?
Yes
No
If Yes, When, Where and What was your experience like?
Please list your main health concerns:
Do you have any serious injuries or ailments?
Yes
No
If Yes, please list these below:
Do you have any allergies or sensitivities?
Yes
No
If Yes, please list these below:
Do you take any supplements or medication?
Yes
No
If Yes, please list these below:
Have you had any abdominal surgery/Colonoscopy in the past 12 months?
Yes
No
If yes, please provide details:
What role does sports and exercise play in your life?
Do you have or experience any of the following:
Type 2 Diabetes
High Blood Pressure
Low Blood Pressure
Chronic Fatigue
Heart Disease
High Cholesterol
IBS
Constipation
Diarrhea
Gas
Bloating
White Coating on Tongue
Athletes Foot
Vaginal Thrush
Poor Memory
Joint Pain
Headaches/Migraines
Skin Issues
Insomnia
Fatigue
Dizzyness
Chest Pain
Acid Reflux
Stomach Pain
Jaw Pain
Nausea
Fluid Retention
Cold Hands/Feet
Hair Loss
Swollen Ankles
Menstrual Problems/PMS
How many times/day/week do you have bowel movement?
Do you have any children?
Yes
No
If Yes, How many?
Did you have Natural birth or C section?
How long did you breast feed for?
Is your cycle regular?
Have you had any dental work: filling, crowns, implants?
General Diet
List your general Breakfast meals:
List your general Lunch meals:
List your general Dinner meals:
List your general Snack items:
List your general Drink choices:
Please select your cravings, if any:
Sugar
Coffee
Cigarettes
Alcohol
Other
If other, please list below:
Colon Cleansing Contraindications
Children under 18
Adults over 70 years old or severely weak
Uncontrolled/non medicated stage 2/3 Hypertension
Congestive Heart Failure
Cirrhosis of the Liver
Carcinoma of the Colon
History of Aneurysm/Blood Clots
Fissure/Fistula
Severe Anemia
Pregnancy/First & Last Trimester
GI Hemorrhage/Perforation
Abdominal Hernia
Bleeding/Inflamed Hemorrhoids
Recent Abdominal Surgery
Renal Insufficiency
Active severe Diverticulitis, Colitis, IBS
HIV or any infectious disease
Pre-existing heart defects
Hypertension if not medicated
Do you suffer from any of the above Colon Cleansing Contraindications
*
Yes
No
If Yes, please provide more information:
Full Fast Contraindications
Children under 18
Adults over 70 years old or severely weak
Pregnant women
Severe Adrenal Fatigue
Diabetes Type 1 and Type 2
Cirrhosis or liver disease
Kidney Disease
Alcoholic
Gall Stone Disease
Severe Thyroid Malfunctions
HIV or any infectious disease
Lupus or severe immune dysfunction
Cancer or malignant tumour
Cardiovascular diseases
Serious cardiac problems or heart defects
Anorexia or other eating disorders
Malnourishment or malnutrition
Severe anaemia
Bleeding disorders of the stomach and intestines
Psychiatric disorders or severe Bi-polar
Epilepsy
Pre-existing heart defects
Thyroid problems
Hypertension if not medicated
Do you suffer from any of the above Full Fast Contraindications
*
Yes
No
If Yes, please provide more information:
Goals
What do you do to balance stress?
What is your Current Emotional State?
brief overview, e.g. optimistic, angry, sad, happy, anxious, resentful, jealous, worried, positive etc.
What is the the most important thing you wish to change about your diet to improve your health?
How do you want to feel on a daily basis?
Anything else you want to share?
DISCLAIMER
IMPORTANT NOTE
Before beginning one of our programs, please be advised that your health is your own responsibility! We here at ‘Orion Retreat Centre’ do not profess to be medical authorities or advisors. Should you have any doubts about your health, medications, or any pre-existing conditions, please contact your medical practitioner first.
Arrival time
We will not be responsible for late arrival, in regard to pre-cleanse drinks/ food missed and length of stay at Orion.
Payment
All activities should be paid for prior to the commencement of programs, treatments or workshops.
What to wear
To ensure that guests can enjoy Orion Retreat Centre’s services, please wear comfortable clothing for all treatments and workshops.
Social guidelines
Orion Retreat Centre respectfully request that all detox guests completely refrain from consumption of alcohol and smoking on the premises during their detox program.
Orion Retreat Centre’s therapists are proficiently trained, and all services provided within the Centre are strictly professional. Any inappropriate behaviors towards therapists will automatically result in ending the treatment. Orion Retreat Centre reserves the right to receive full payment for the treatment.
Payment and cancellation policy.
A 24-hour notice is required to re-schedule the appointment or workshop. Any cancellation with less than 3 hours’ notice will incur a 50% cancellation fee. Full charges will be imposed for a no show. A 14 day notice is required to re-schedule a detox program, subject to space availability. Any cancellation with less than 14 days notice will incur a 50% cancellation fee. We have a no refunds policy for our detox programs once they have been started.
Age
Orion Retreat Centre only accepts detox guests who are at least 18 years of age, or have consent from Parents or guardians. Children are welcome at Orion Retreat if they are accompanying their parents or guardians to Thailand.
Special Consideration
Whilst we are happy and capable to deal with medical conditions we recommend that if you have high blood pressure, heart conditions, are pregnant, have any pre-existing mental conditions or have any other medical complications you are advised to consult your doctors before signing up for any of our services. Kindly inform your therapist or the detox manager of any existing medical conditions prior to commencing any wellbeing programs at Orion Retreat Centre.
Disclaimer
Orion Retreat Centre's treatments are provided for general wellbeing purposes only and are not intended to be a substitute for professional medical treatment for any condition, medical or otherwise. Orion Retreat Centre and its management and staff hold no responsibilities on all liabilities, claims, expenses, damages and losses, including legal fees, arising out of or in connection with the centre and spa treatments, services and/or facilities.
Orion Retreat Centre Release of Liability and Waiver
By signing this Release of Liability and Waiver, I will assume full responsibility for any risks, injuries, or damage, known or unknown, which I might incur as a result of participating in the program or activities or excursions. This includes, without limitation, my use of the resort and facilities, pool, steam room, parking area, beach, road or any equipment and my participation in any part of the program, activity, class, training or instruction.
I am voluntarily participating in the program or activities or excursion and assume all risk of injury or death to me or the contraction of any illness or medical condition that might result, or any damage, loss or theft of any personal property. I agree on behalf of myself (and my personal representatives, heirs, executors, administrators, agents and assigns) to release and discharge Orion Retreat Centre and its affiliates, employees, agents, representatives, successors and assigns from any and all claims or causes of action (known or unknown) arising out of my participation in the program, activities or excursions (including, but not limited to, our negligence).
This Release and Waiver of liability includes, without limitation, injuries which may occur as a result of (a) my use of any equipment or facilities which may malfunction or break, (b) our improper maintenance of any equipment or facilities, (c) our negligent instruction or supervision, (d) my slipping and falling while on the premises or on activities or excursions, and (e) my travel to or participation in the program.
I agree that neither I nor any person or entity acting on my behalf has filed or will file, charge, claim, sue or permit to be filed, charged or claimed, any legal or equitable action against any staff of Orion Retreat Centre and Anahata Wellness Resort, involving any matter occurring at any time or related in any way whatsoever to travelling to or participating in any of our programs or activities or excursions.
Orion Retreat Centre will not accept responsibility for any loss, damage or theft of valuables brought into the resort.
*
I confirm that I have read the Orion Retreat Centre terms and Conditions policy agreement and agree to all conditions set forth without exception. I also confirm that the information I have provided is correct to the best of my knowledge. By ticking the confirm box, I am agreeing to the equivalent of an electronic signature stating that I am in full agreement with all Orion Retreat Centre terms and conditions.
Join Our Newsletter for Updates on Promotions, Wellness Tips, and More!
SUBSCRIBE!
You have Successfully Subscribed!