Pre-Arrival Questionnaire Pre-arrival Questionnaire "*" indicates required fields Step 1 of 4 25% PRE-ARRIVAL QUESTIONNAIRE Filling in this form is a very important part of your upcoming Program. It will help you and also us to prepare optimally so that you can get great results. Please take your time with the answers - some answers might require a little bit of reflection and thinking.Name* First Last Email* Gender*MaleFemaleOtherYour Age* 18-25 25-30 31-40 41-50 51-60 61 and above Place of Origin*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePlace of Residence*AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwePlease enter today's date* DD slash MM slash YYYY Which Program did you book with us* 3 Day Detox 5 Day Detox 7 Day Detox 8 Day Detox 10 Day Detox 12 Day Pancharkarma 21 Day Pancharkarma 28 Day Pancharkarma 14 Day Weight Management 21 Day Weight Management 7 Day Rejuvenation 10 Day Day Rejuvenation Executive Program Other Please specify*When is you program start?* DD slash MM slash YYYY Are you a returning customer?* Yes No How did you hear about AmrtaSiddhi Ayurvedic Centre?* Google Search (or any other search engine) Recommendation from another person Influencer/Blogger Ubud Community magazine Through my Yoga Teacher Training Bali Spirit Website Online Article / Landing page Other Please specify*Please state the name of your <Person> or the <Influencer/Blogger> who has recommended you to come to us.* PERSONAL REFLECTIONSPlease list up to 5 reasons that have motivated you to join a Program at AmrtaSiddhi:*Describe the specific outcomes you are wishing to generate from your participation in the Program:*Describe what actions (if any) you have already pursued (or are currently pursuing) to improve your state of Health and Well-being:*What do you consider the single biggest challenge that you are currently facing in your life?*Please describe briefly how resolving this issue would impact your life?*How difficult has it been for you to find solutions or get valuable results for the challenge that you have been facing?*1 = very difficult, 5 = not difficult 1 2 3 4 5 How long have you had this problem for?* not applicable just recently emerged around 1 year more than a year between 2 and 5 years more than 5 years YOUR STATE OF HEALTHPlease describe your current state of health:*Are you currently taking any medications?* Yes No Please specify your medications here.*Are you currently (or have been during the last 12 months) under the Medical Care of a Physician or other Health Care Practitioner?* Yes No Please list the reasons why you are under Medical Care.*Have you previously been diagnosed with any Medical Conditions by a Physician or other Health Care Practitioner?* Yes No Please list the diagnosis.*Are you currently (or have been during the last 12 months) under the care of a Mental Health Professional?* Yes No Please list the reasons you are under the care of a Mental Health Professional.*Do you have any addictions?* Yes No Please specify if you have answered the last question with <Yes>.* YOUR DAILY HABITSHow often do you drink alcohol?* Never Occasionally 2-3 times a week Daily Do you smoke?* No Sometimes Yes, daily Do you take recreational drugs?* No, never Yes, from time to time Yes, regularly Please specify, which drugs you are using:*Do you do any physical exercise or workout routines?* No Yes, 1-2x per week Yes, 3-4x per week Yes, daily Please specify what kind of workout you are doing*Do you have any special dietary requirements, allergies or food intolerances?* No Yes Please specify:*Do you have any other special requests?* No Yes Please specify:*Confirmation & DeclarationConfirmation* I confirm, that I have filled in this pre-arrival form for myself.Declaration* I have answered all questions truthfully and to the best of my knowledge and understanding.Please confim with your initials here:*Done! Thank you very much for taking the time to fill in this form. We look forward to welcoming you to our Centre and helping you to improve your health and well-being!CommentsThis field is for validation purposes and should be left unchanged.