Individual trip with consultation

Please fill the form below to allow me to prepare your consultation.

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

Home Phone*

Gender*

Date of Birth*

Weight in kilograms*

Height in centimeters*

Are you flying to Manila or Clark?*

	Manila
	Clark

Are you on a Group or Individual trip?*

	Group
	Individual

Arrival date, time, and flight details?*

Return Flight Date, Time & Number:

How many people with you?*

	Just myself
	Myself + 1
	Myself + 2
	More than 3 of us

Are you bringing a wheelchair?

	Yes
	No

Next of kin name, phone number and email address to contact in case of emergency:

Your Email address*

Your phone number, including country code*

Which is your favorite method for the consultation? *

	Face to face in the Philippines
	WhatsApp
	Skype

What is your id for the above?*

Your Country*

Nearest Big City To You*

What is your MAIN health concern?*

Any other health problems?*

What medication(s) are you taking?*

What vitamins/ herbs are you taking?*

Do you exercise? Which and how often?*

How much stress are you under?*

	1 Very little
	2 A little but manageable
	3 Medium, it depends on the day
	4 Quite a lot but not extreme
	5 A lot every day

How many coffee or cafeinated tea do you drink?

	Never
	Maybe 2 to 4 a week
	1 or 2 a day
	3 or 4 a day
	More than 5 a day

Do you eat any organic foods? Which and how often?**

I eat at least 3 vegetables daily for lunch and dinner*

	True
	False

I eat chicken*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat pork or beef*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Other meat you eat*

I eat eggs*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat fish or other sea food

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat gluten products such as bread or cakes or biscuits or floury products (i.e. pasta..) or wheat food *

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat dairy products from cow, goat, sheep, etc..*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

How often do you eat seeds, nuts, avocados, hummus, coconut flesh or milk, or other oily products?

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I use oil for frying or in salad

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat tropical fruits (oranges, bananas, kiwi, mangoes, etc..)*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

I eat tin food or pre-prepared meals*

	Yes
	No

I always check products labels to make sure I don't eat sugar*

	Yes
	No

I always check labels to make sure I don't eat any harmful chemicals (additives, coloring, etc..)*

	Yes
	No

If you have only recently changed your diet to the above. Please state when you changed it, and what your previous diet was*

I smoke*

	Yes
	No

I drink alcohol*

	6 or more times a week
	3 to 5 times a week
	1 to 2 times a week
	Never

Other Comments*

How did you hear about my consultation?*

	Google search
	Other search engine
	Your Blog
	Word of mouth
	I have ordered from you before
	Facebook
	Twitter
	I can't remember

Confirm your acceptance of our Agreement form on behalf of ALL travelers. Link: www.therapies.com/agreement.html **

	I/we have read it and we ALL agree to its terms
	I/we have not read it but agree to it anyway

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