Guest Health Questionnaire

The information you provide by completing this questionnaire will allow our medical doctors to define your personal program here at The Farm.

Last Name: / First Name: / Title:
Ethnic Origin: / Civil Status: / Gender:
Date of Birth: / Age: / Height: / Weight:
Telephone Number: / Email:
Nationality: / Country of Domicile:
  1. Please underline/highlight the statement that BEST describes the intentions of your stay:
I want to have a vacation and do activities at my own time.
I want to experience healthy living and follow a regimen to kickstart my intended lifestyle shifts and develop health habits for sustainable health empowerment.
I have issues that are having a negative impact on my health and quality of life. I am seeking help to correct the issues and reverse them.
I want to experience everything that the FARM has to offer.
2. Please, indicate your main health concern, if any.
3. What are your goals for your stay at the Farm?
4. Please state thediseases, symptoms, or disorders that you are experiencing for the last 6 months:
5. Please list medications utilized during the course of the past six (6) months. Please, include vitamins and dietary supplement
  1. Have you undergone surgery in the last 2 years?
If yes, please indicate the reason for the surgery and the date the surgery was performed.
  1. Have you had colon hydrotherapy or other colon cleansing treatment before?
If yes, please indicate the date, the name of the institution and the country
  1. Please, indicate the MAXIMUM duration you are able to stay:
The Medical Doctors will prescribe the duration of the program on the basis of your state of health and the health goals you have defined, as well as allowable time away from work and family.
  1. Please, provide information regarding any known ALLERGIES and food intolerance that you may have:
For spa considerations, are you skin allergic to coconut oil?
  1. Do you smoke cigarettes, cigars? How often?

  1. Do you drink alcoholic beverages? How often?

  1. How many meals do you eat per day? What kind of food do you usually eat?

  1. What causes your stress?

  1. Are there any other concerns or information that you wish to add that may assist us in maximizing your stay at the Farm?

  1. The Farm at San Benito offers a wide variety of services and private sessions. Please underline/highlight any areas that are of interest to you during your stay.
Integrative Medicine (Holistic Consultation, Brain Biofeedback, Live Blood Analysis, Capillary Scan, etc.)
Body Treatments (Massages, Aromatherapy, Body scrubs, Herbal wraps, etc.)
Detoxification (Colon hydrotherapies, Rectal infusion, Liver cleanse, Internal Organ compresses, Magnetic Clay Foot Treatment, Body Salt Baths, Tibetan Steam Therapy,etc.)
Exercise/Movement (Yoga, Taichi, Qigong, Personal Training, Power walk, Horticultural walk, Oil of Life tour,etc.)
Acupuncture [Meridian-based Body Acupuncture, Ear Acudetox (aka NADA Protocol) with Ear Acupressure, Beautifying Acupuncture]
Body-Mind Alignment [Harvard/Hopkins Psychological Assessment Tests for anxiety, depression and trauma, Psychoemotional Clearing, Guided Meditation, Guided Visualization, Sleep Therapy, Neurogenic Release (technique for releasing unconscious blockages), Eye Movement Desensitization and Reprocessing, etc.]
Healing Energy (Harmonizing Flow sessions, Jin Shin Jyutsu, Usui Reiki, Craniosacral therapy, BodyTalk Access, touchtherapy,etc.)
Food (consultations with a nutritionist, menu design, healthy weight, Food Preparation Class, etc.)
Outdoor activities (Golf, fishing, etc.)
Kids & Teen Services (for guests ages less than 17)

* For your best health interest and with your permission, your program inclusion can still changeAFTER consultation and physical check-up with our medical doctor based on health concerns not previously mentioned.

* Charges will apply for additional services outside your pre-booked program

THE FARM AT SAN BENITO

Resort Address: 119 Barangay Tipakan, Lipa City, Batangas, Philippines Mobile No. (+63)9188848078

Sales and Reservations Office: Shop 11, G/ F, The Peninsula Manila, Corner of Ayala and Makati Avenues, Makati City, Philippines

Tel. Nos. (63 2) 884 8074 Mobile No.(+63) 9188848080

Email: / Website: