Pre-Booking Guest Medical Screening Form - Tre Wellness

Close

An Integrative Wellness Retreat

Pre-Booking Guest Medical Screening Form

Please enable JavaScript in your browser to complete this form.

First Name *

Last Name *

Age *

Date of Birth *

Father/Spouse name

Gender *

Height (in cms)

Weight (in kgs) *

Blood group

Occupation

Marital status

Mobile Number *

Email *

City *

Address

Emergency contact name & contact number

Do you have any health issues? *

Yes
No

List your health issues

List your current Medications / Supplements *

1) Have you undergone any surgery in recent years? *

Yes
No

If yes, please give details:

2) Are you suffering from any infectious disease or skin disease? *

Yes
No

If yes, please give details:

3) Are you suffering from any heart disease or have undergone angioplasty/bypass/open heart surgery? *

Yes
No

If yes, please give details:

4) Do you have any past/present history of psychiatric medication/intervention? *

Yes
No

If yes, please give details:

5) Are you suffering from any kind of kidney/ liver/ lung disease? *

Yes
No

If yes, please give details:

6) Did you have any episodes of seizure/epilepsy in the past 5 years? *

Yes
No

If yes, please give details:

7) Do you suffer from any type of hernia? *

Yes
No

If yes, please give details:

8) Are you physically or visually disabled in anyway? *

Yes
No

If yes, please give details:

9) Can you walk 1 Kilometre without support? *

Yes
No

If no, please give details:

10) Are you suffering from any allergies? *

Food
Medicines
External allergies
None

Please explain in detail:

11) Have you become reliant on any of the below substances? *

Tea
Coffee
Smoking
Alcohol
Zarda
Drugs
Paan masala
Substance
E-cigarettes
Tobacco
Sugar
None

12) Purpose of your visit to trē wellness? *

Experience
Detox
Healing
De-Stress
Rejuvenation
Lifestyle management

13) Preferred days for your stay at Tre Wellness

From *

To *

14) Preferred type of accommodation

Executive room
Premium room
Suite

15) In case of re-admission:

Previous date of admission

Client ID / Admission number

16) How did you come to know about trē wellness? *

Google search
Social Media
Personal reference
Others

If others, please specify

17) Have you been to any other naturopathy / ayurveda / wellness centre before? *

Yes
No

If yes, please mention name and duration of stay

18) For Foreign nationals / Non-resident Indians / Overseas Citizen of India

Passport number

Date of issue

Place of issue

Visa duration

Viewing Sample Itinerary

Are You Looking For
Stress Relief & RelaxationBeauty & Skin RejuvenationDetox & Digestive CareHealthy Aging & LongevityMetabolic & Hormonal BalanceMood & Emotional Well-beingWeight & Lifestyle ManagementPost- Injury or Illness RecoveryChronic Condition & Disease ManagementSleep Restoration & Enhanced EnergyOverall Heath & Vitality

I agree to the Privacy Policy and would like to receive health and wellness updates from Trē Wellness.

Free Doctors Consultation

MrMs

First Name*

Last Name*

Age*

Email*

Phone Number*

City*

Preferred Check in Date*

Message

Enquire now

MrMs

First Name*

Last Name*

Age*

Email*

Phone Number*

City*

Preferred Check in Date*

Message

Offers Popup Content

Call Now Button