Your Group Trip to the Philippines is Booked
Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
Gender*
---Select--- Male
Female
Year of birth*
Your weight in kgs
Your height in cms
Email address*
City*
Country*
Cell Phone Number including country code*
Specify which to use to call you*
Your id for the above including country code if needed
Next of kin name, phone number and email address to contact in case of emergency:*
If sharing a room, full name of your partner
Day & Time of arrival in Manila*
Return Flight Date & Time*
What medication(s) are you taking?*
What vitamins/ herbs are you taking?*
Do you exercise? Which and how often?*
How much stress do you have daily?*
If you intend to avail of my consultation please let me know of your disease(s) here. If you were diagnosed less than 2 years ago, please fill the rest of this form to tell me what your diet was like 2+ years ago*
How many cups of coffee did you drink every day>*
Did you eat any organic foods? Which and how often?*
Dis you eat at least 3 vegetables daily for lunch and dinner*
I ate chicken*
I ate pork*
I ate beef
Other meat I used to eat:*
I ate eggs*
I ate fish or other sea food*
I ate dairy products from cow, goat, sheep, (butter, yoghurt)etc..*
I ate gluten products such as bread or cakes or biscuits or floury products (i.e. pasta..) or wheat food *
How often did you eat seeds, nuts, avocados, hummus, coconut flesh or milk, or other oily products?*
I used oil for frying or in salad*
I ate tropical fruits (oranges, bananas, kiwi, mangoes, etc..)*
How many times a week did you eat cakes, refined sugar (all colours), chocolate, sweets, other sweetened products?*
I ate tin food or pre-prepared meals*
I always checked labels to make sure I don't eat any harmful chemicals (additives, coloring, sugar, etc..)*
I used to drink alcohol over 2 years ago
I still drink alcohol*
I used to smoke over 2 years ago*
I still smoke
If you have only changed your diet less than 2 years ago, please state when you modified it, and what changes you made*
Other comments
How did you hear about our trips?*
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Bing or Yahoo Search
Other search engine
Word of mouth recommendation
Facebook
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I can't remember
Confirm your acceptance of our Agreement at www.therapies.com/agreement.html on behalf of ALL travelers*