Questionaire

SUGAR HUT RESORT & PATTAYA INTERNATIONAL HOSPITAL

FASTING - DETOXIFICATION WEIGHT LOSING PROGRAM

DETOXIFICATION QUESTIONAIRE
1	YOUR NAME
2	GENDER	AGE STATUS
3	CONTACT ADDRESS
4	COUNTRY
5	E-MAIL
6	TELEPHONE
7	OCCUPATION
8	MINOR HEALTH PROBLEM	YES NO
	PLEASE SPECIFY
9	MAJOR HEALTH PROBLEM	YES NO
	PLEASE SPECIFY
10	REGULAR MEDICATION
11	ANY JOINT PAIN?	YES NO
12	ANY INFLAMMATIONS/SWELLINGS	YES NO
	PLEASE SPECIFY
13	WHAT IS THE MAIN REASON THAT YOU WOULD LIKE TO DETOXIFY?
14	ARE YOUR SERIOUS ABOUT THE DETOXIFICITION?	YES NO
15	HOW SOON ARE YOU ABLE TO START THE PROGRAM?