Amity Wellness Registation Form

Personal Information

Full Name *

Arrival Date

Returning Guest

Yes No

Accompanying Guest?

Occupation

Phone Number

Email Address *

Country of Departure

Emergency Contact *

Age

Height (cm)

Weight (kg)

Blood Pressure

High Medium Low Unsure (Please note: If your blood pressure is 140/90mmHg or higher and is un-medicated, you will be referred to the local hospital for a check up prior to commencing one of our wellness programs)

Last Full Medical Assessment:

Medical Conditions

Family History of Illness/Disease (provide details)

Current Medical Conditions

Medications

Important Information: The use of prescribed medications will result in either the complete removal of certain cleansing supplements to avoid interactions or a modification to the consumption time of the regular schedule.

Medication 1

Prescribed for

Medication 2

Prescribed for

Medication 3

Prescribed for

Medication 4

Prescribed for

Medication 5

Prescribed for

Please advise us if any of the following cleansing supplements are not advised for consumption by your GP or licensed medical practitioner due to your current medication or health condition: (Turmeric, Milk Thistle, Activated Charcoal, Tibetan Hardd, Coconut, Garlic, Chlorophyll, Spirulina, Avala, Flaxseed, Psyllium Husk, Jicama, Probiotics, Bee Pollen, Ginger, Baangra or any other superfoods)

Previous Serious Illnesses

Health Checklist

Do you have a Heart Condition?

Yes No

Do you have any Infectious Diseases?

Yes No

Are you Diabetic?

Type 1 Type 2 Non-Diabetic

Do you have any Thyroid problems?

Yes No

Do you have a history of Aneurysm/Blood Clots?

Yes No

Do you have diagnosed IBS, Diverticulitis or Colitis?

Yes No

Do you have an Abdominal Hernia?

Yes No

Do you have any Psychiatric Illness?

Yes No

Have you ever suffered with Alcoholism or Substance Abuse?

Yes No

Have you ever suffered with an Eating Disorder?

Yes No

Do you have impaired Liver or Kidney function?

Yes No

Do you have any breathing difficulties?

Yes No

Do you have any adrenal fatigue?

Yes No

Do you have Bleeding/Inflamed Hemorrhoids?

Yes No

Do you have severe anemia?

Yes No

Are you suffering from Depression?

Yes No

Do you suffer with hypoglycemia (shaky, dizziness, confusion, weakness, fatigue, elevated pulse if skipping meals)?

Yes No

Do you have digestive issues (provide details)?

Yes No

Do you suffer with reoccurring Urinary Tract Infections?

Yes No

Have you had a colonoscopy?

Yes No

If yes, please provide details of any irregularities:

Have you had any abdominal surgery in the past 12 months?

Yes No

Have you ever been hospitalised?

Yes No

If yes, please provide details:

Do you have any allergies?

Yes No

If yes, please provide details:

Do you have any food Intolerances?

Yes No

If yes, please provide details:

Have you done colon cleansing before?

Yes No

Do you have a daily bowel movement?

Yes No

Do you have Asthma?

Yes No

Do you have candida?

Yes No

Do you have amalgam dental fillings?

Yes No

Have you completed a cleansing program before?

Yes No

If Yes, please provide retreat name and type of cleanse?

If Yes, When did you last cleanse?

Less than 1 year 1 year to 2 years More than 2 years Never

Are you allergic to any of the following?

Turmeric, Milk Thistle, Activated Charcoal, Tibetan Hardd, Coconut, Garlic, Chlorophyll, Spirulina, Avala, Flaxseed, Psyllium Husk, Jicama, Probiotics, Bee Pollen, Ginger, Baangra or any other superfoods?

Yes No

List any Supplements you are taking:

Menstruating

Peri-Menopausal Menstruating Post-Menopausal Not-Applicable

Symptoms Checklist

Bloating?

Yes No

White Coating on Tongue?

Yes No

Athletes Foot?

Yes No

Nail Fungus?

Yes No

Vaginal Thrush?

Yes No

Poor Memory?

Yes No

Joint Pain?

Yes No

Headaches or Migraines?

Yes No

Skin Issues?

Yes No

Insomnia?

Yes No

Fatigue?

Yes No

Dizziness?

Yes No

Chest Pain?

Yes No

Tingling in Arms?

Yes No

Acid Reflux?

Yes No

Stomach Pain?

Yes No

Jaw Pain?

Yes No

Tremors?

Yes No

Nausea?

Yes No

Fluid Retention?

Yes No

Cold Hands/Feet?

Yes No

Hair loss?

Yes No

Swollen Ankles?

Yes No

Menstruation Problems/PMS?

Yes No

Gas?

Yes No

Diet Checklist

Weekly Alcohol Intake:

High Medium Low None

Daily Water Intake (Per Day):

High > 2 Litres Medium 1 - 2 Litres Low < 1 Litre

Daily Tobacco Intake:

High Medium Low None

Recreational Drugs:

Artificial Sweetener

Daily Weekly Rarely Never

Candy/Desserts/Refined Sugar

Daily Weekly Rarely Never

Refined Carbohydrates

Daily Weekly Rarely Never

Carbonated Beverages

Daily Weekly Rarely Never

Daily Coffee Intake

High Medium Low None

Fast Food

Daily Weekly Rarely Never

Fried Food

Daily Weekly Rarely Never

Margarine

Daily Weekly Rarely Never

Refined Flour/Baked Goods

Daily Weekly Rarely Never

Packaged Foods

Daily Weekly Rarely Never

Milk/Dairy

Daily Weekly Rarely Never

Fruits

Daily Weekly Rarely Never

Vegetables

Daily Weekly Rarely Never

Nuts/Seeds

Daily Weekly Rarely Never

Lifestyle Checklist

Average Nights Sleep:

Exercise per week

x 3+ x 1-2 x 1 Never

Pollution:

High Medium Low

Diet often

Daily Weekly Rarely Never

Work over 50 hours/week

Always Usually Occasionally Never

Stress

Excessively Often Sometimes Never

What do you do to balance stress?

Current Emotional State?

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

What would you like to achieve at Amity Wellness

Body Mind Detox Facebook Group

Would you like the opportunity to be added into the Body Mind Detox private Facebook support group, which offers some fantastic pre and post cleanse advice along with health and wellness articles. The group is interactive so please feel free to ask any questions.

Yes No

Please provide Facebook email address to receive invite

What is your main health, wellness or nutrition questions that you have? (These questions can be used to help us formulate more useful posts on the Body Mind Detox Private group)

Please note: sometimes magical moments and group photos are captured during some of our activities, walks or demonstrations and might be used by Amity Wellness.

If you take beautiful pictures during your stay, we would love to receive any photos that you wish to share with us or other guests.

If you don’t wish to have your photo taken simply let us know.

Solo/individual pictures allowed?

Yes No

Group photos allowed?

Yes No

Body composition results allowed?

Yes No

Wellness Program Structure

Combination Of Colon Cleansing + Inflammation Pod Combined With Oxygen Therapy

Contraindications

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?

Additional Notes?

Amity Wellness Terms and Conditions Policy Agreement

The information provided in this Report contains information for the exclusive use of the above named recipient and Amity Wellness only, and contains confidential, and privileged information. If you are not the above named recipient or have not been given permission by the person, you are prohibited from reading or utilizing this report in any way, and you are further notified that any distribution, dissemination, or copying of this Report is strictly prohibited.

All information provided by Amity Wellness or any of the employees is provided for educational purposes only, including without limitation the dietary recommendations or advice regarding nutritional supplementation or holistic protocols. Neither this Report, nor any of the information provided at Amity Wellness, is intended for, or should be used for the purpose of, medical diagnosis, prevention, or treatment, including self-diagnosis, prevention, or treatment. Amity Wellness retreats can not be used as a substitute for professional medical care, and should not be relied upon in diagnosing or treating a medical condition, ailment, or disease.

The information provided in the holistic report generated from your answers are for general reference only, and are not intended to be guidelines for any specific individual. The information set forth in this Report are for educational purposes only, and are not intended to be, nor should they be construed as, a claim or representation of medical diagnosis or treatment.

Neither this Report, nor any information provided by Amity Wellness or any of the employees, should be considered complete, or exhaustive. This report does not contain information on all diseases, ailments, physical conditions or their treatment.

I clearly understand that Amity Wellness is an Educational Center, not a medical center, that no members of the staff or management at Amity Wellness hold any officially recognized medical qualifications, and that all of Amity Wellness Co. Ltd. There are no doctors or licensed Physicians available as the nature of the business is alternative and holistic. Natural Healing services are simply a sharing of products and procedures that have been tried and tested over a period of time by us personally, and by our previous guests.

I understand that testimonials from previous Amity Wellness guests do not imply that similar results will happen for me as a result of my use of Amity’s services and/or products. I understand that Amity has no reliable scientific evidence to suggest that the experience of any testimonial is due to the use of Amity’s services and/or products. These testimonials are not intended to recommend any product available from Amity as a drug, and/or any service as a diagnosis for specific illnesses or conditions, or complications. I understand that Amity Wellness makes no medical claims as to the benefits of any of their products or services to improve medical conditions.

I understand that in no way can Amity Wellness Co.Ltd, and/or it’s employees be held accountable and/or responsible for any outcomes attributable and/or consequential to any instructions, products, demonstrations, therapies, treatments, machines, and suggestions made by Amity’s staff, management, owners, therapists or agents.

All Therapists are independent contractors and Amity Wellness will not be held responsible for any of the Therapists actions, recommendations or suggestions.

By agreeing to the terms and conditions outlined, you are confirming that to the best of your knowledge that you have no known allergies or sensitivities to any of Amity Wellness herbs, supplementation, foods or superfoods as outlined in the program.

You also confirm that you have consent from your doctor that you are in good health to complete a cleansing program with all inclusions available at the Amity Wellness retreat unless otherwise stated on the registration form contraindications list. The absence of a warning for a given drug or supplement or any combination thereof provided by Amity Wellness should in no way be construed to indicate that the drug or supplement or any combination thereof is safe, effective, or appropriate for you. Statements made about a supplement, product or treatment may not have not been evaluated by the Food and Drug Administration (FDA) and any mentioned supplement, product or treatment is not intended to diagnose, treat, cure or prevent any disease. You are encouraged to confirm and review all information regarding any medical condition or the treatment of such condition with your physician.

NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE, DELAY SEEKING MEDICAL ADVICE OR TREATMENT, OR STOP CURRENT MEDICAL TREATMENT OR PRESCRIPTION MEDICATIONS. ALWAYS CHECK WITH YOUR PHYSICIAN PRIORING TO PROCEEDING ANY WELLNESS PROGRAM AT AMITY WELLNESS THAT THERE ARE NO CONTRAINDICATIONS RELATING TO YOUR CURRENT MEDICAL CONDITIONS OR PRESCRIPTION MEDICATIONS.

Consult your physician or a qualified healthcare practitioner regarding the applicability of any of the products, protocols, supplements, foods, information or materials provided in by Amity Wellness in regards to your symptoms, medical conditions or health. Always consult your physician before beginning a new treatment, cleansing program, diet, exercise, fitness plan, or health plan or wellness program, and before taking any drug, supplement, or any combination thereof; or if you have questions or concerns about your health, a medical condition, or any plan or course of treatment.

If you think you are in ill health or have a serious medical condition or compromised detoxification capacity then you should not proceed with a wellness program at Amity Wellness and should instead seek medical attention form a qualified physician.

Further, I accept that there are no refunds for any unused portion of accommodation and/or wellness programs after the first registration meeting has been completed and the program has commenced.

I confirm that I have read the Amity Wellness 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 Amity Wellness terms and conditions.

AMITY WELLNESS REGISTRATION FORM

Personal Information

Full Name *

Arrival Date

Returning Guest

Accompanying Guest?

Occupation

Phone Number

Email Address *

Country of Departure

Emergency Contact *

Age

Height (cm)

Weight (kg)

Blood Pressure

Last Full Medical Assessment:

Medical Conditions

Family History of Illness/Disease (provide details)

Current Medical Conditions

Medications

Medication 1

Prescribed for

Medication 2

Prescribed for

Medication 3

Prescribed for

Medication 4

Prescribed for

Medication 5

Prescribed for

Previous Serious Illnesses

Health Checklist

Do you have a Heart Condition?

Do you have any Infectious Diseases?

Are you Diabetic?

Are you Insulin dependant?

Do you have any Thyroid problems?

Do you suffer with Hypothyroidism or Hyperthyroidism?

Do you have a history of Aneurysm/Blood Clots?

Do you have diagnosed IBS, Diverticulitis or Colitis?

Do you have an Abdominal Hernia?

Do you have any Psychiatric Illness?

Have you ever suffered with Alcoholism or Substance Abuse?

Have you ever suffered with an Eating Disorder?

Do you have impaired Liver or Kidney function?

Do you have any breathing difficulties?

Do you have any adrenal fatigue?

Do you have Bleeding/Inflamed Hemorrhoids?

Do you have severe anemia?

Are you suffering from Depression?

Do you suffer with hypoglycemia (shaky, dizziness, confusion, weakness, fatigue, elevated pulse if skipping meals)?

Do you have digestive issues (provide details)?

Do you suffer with reoccurring Urinary Tract Infections?

Have you had a colonoscopy?

If yes, please provide details of any irregularities:

Have you had any abdominal surgery in the past 12 months?

Have you ever been hospitalised?

If yes, please provide details:

Do you have any allergies?

If yes, please provide details:

Do you have any food Intolerances?

If yes, please provide details:

Have you done colon cleansing before?

Do you have a daily bowel movement?

Do you have Asthma?

Do you have candida?

Has your Candida been Diagnosed?

Do you have amalgam dental fillings?

Have you completed a cleansing program before?

If Yes, please provide retreat name and type of cleanse?

If Yes, When did you last cleanse?

Are you allergic to any of the following?

List any Supplements you are taking:

Menstruating

Symptoms Checklist

Bloating?

White Coating on Tongue?

Athletes Foot?

Nail Fungus?

Vaginal Thrush?

AMITY WELLNESS
REGISTRATION FORM