Please complete the form below

This form is very comprehensive. We need to know as much information about you as we can so that we can build the right programme for you and your body. All of your details are kept in the strictest confidentiality and our wellbeing experts have all signed confidentiality agreements with Bodhimaya.

If you do not wish to answer any other question or don't know the answer then please leave the field blank. However, please be aware that we need to know as much information about your health as possible so that we can build the right programme for your body. We also need to know about your medical history and health issues because this may effect your suitablility to a particular Bodhimaya Programme.

The final statement on this form must be acknowledged and signed by ticking the boxes underneath the statement.

PLEASE FILL THIS FORM OUT WITHOUT MOVING BACK OR FORWARD ON YOUR BROWSER. IF YOU DO, THE FORM WILL BE LOST AND YOU WILL HAVE TO START AGAIN. Please also ensure you have internet connection before you hit the submit button. 

Name
Name
Address
Address
Date of birth
Date of birth
Health Profile
*** Please list the health problem, what you are currently doing to manage this health problem, the onset of the problem and how long you have suffered with it ***
Please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc
If yes please send the test results to info@bodhimaya.com
*** Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) nutritional supplements, herbal or homeopathic remedies. List the medication or remedy, what condition it is being used for, the exact dose and the frequency of use ***
Antibiotic history
Body Scan and specific health questions
Please check off any of the symptoms that you regularly experience and answer the following questions to the best of your abilty
Head
Hair
Mouth and Throat
Eyes
Ears
Chest
Gut
Do you regualrly experience any of the following digestive symptoms?
Muscles
Mind, Mood and Stress
e.g. city, farm, office or highly stressed
Genitals
Joints
Skin
Nails
Hands
Legs and Feet
Important Symptoms
All unusual symptoms should be reported to your doctor, however the following symptoms may mean you need immediate medical care and should be reported to your doctor as soon as possible
Your Vital Statistics
Family History
Do you have a family history of disease or allergies? (e.g. heart disease, diabetes, asthma, etc) State the disease, age of onset and gender of the family member. This section is especially important for those doing the BodhiGen Genetic Analysis
Exercise
Toxic Exposure
Do you do any of the following?
Your Energy Levels
Are any of the following true?
Eating Habits
Women Only
Men can scroll down to the next section - Men only
Do you suffer from any of the following?
Menstruating Women
Do you experience any of the following?
Menopausal Women
Do you experience any of the following?
Men Only
Women can scroll down to the next section - healthcare providers
Do you experience any of the following symptoms?
Healthcare Providers
We will not contact your GP without your permission
I have disclosed all the relevant information applicable to the retreat, the consultations I will have and my health status at this point in time. I consent for the information provided to be used by my Nutritional Therapist and where necessary other Bodhimaya Experts, and for them to liaise with appropriate health professionals where necessary.
I understand and acknowledge that Bodhimaya and the Bodhimaya Experts are wellbeing professionals and NOT doctors or medical professionals. Bodhimaya does not give medical advice, treatment, diagnosis or cure any condition. Bodhimaya is ONLY focused health optimisation and on helping you manage your health more effectively by providing educational information on diet, supplements and lifestyle recommendations. You must always discuss any recommendations with your doctor and ensure they agree with any course of action.
If you have any medical issue you must consult your doctor immediately. Bodhimaya is not a subsitute for medical advice. You must also consult your doctor and ensure that it is safe for you to make dietary changes or embark on any juice fast, tailored cleanse or any other Bodhimaya Programme, Bodhimaya Retreat or act on any of the recommendations made by any of our experts.
Please confirm the following by clicking the boxes below *
All statements must be agreed to use any of Bodhimaya's services
Thank you. The Form is now complete. Please Ensure you have internet connection before you hit the submit button