Health Questionnaire

Health Questionnaire

Guest Information
  • Personal Information

  • Date Format: MM slash DD slash YYYY
  • Name, Contact Details, Country of Residence
  • Health History

  • General Diet

  • 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
  • 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
  • Goals

  • brief overview, e.g. optimistic, angry, sad, happy, anxious, resentful, jealous, worried, positive etc.
  • 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.

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