THE LIFECO WELL-BEING CENTERS Survey

Please fill out the form before starting your Detox Program. The LifeCo is not responsible for any health problems that might occur due to wrong or missing health information provided within this form. Intake of food or beverages from outside are not allowed in our programs.

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* Email Address

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* Other Personal Information

Full Name *

Phone Number

Nationality

Country of Residence

Email *

Phone Number *

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* How did you hear about The LifeCo?

Website

Social Media

Friend

Google Search

Press

Other (please specify)

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* Gender

Male

Female

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* Which Center will you attend during your detox experience?

Antalya

Bodrum

Phuket

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* When will you have your detox experience?

Start Date

Date

End Date

Date

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* Reasons for Joining a Detox Program

To get rid of toxins in the body

To improve a health condition

To strengthen the immune system

To lose weight

To eliminate the effects of cigarettes, alcohol or other substances

Physical and mental fatigue

Periodic care

Other (please specify)

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* Did you do detox before?

Yes

If YES: When and Where?

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* Have you had an enema or colon cleansing before?

Yes

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* Are you pregnant or breastfeeding?

Yes

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* Have you been through chemotherapy / other intensive medical treatment in the last 6 months?

Yes

If YES: Can you please specify..

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* Ongoing or past conditions

High Blood Pressure

Diabetes Type II

High Cholesterol / Triglycerides

Hormonal Disease

Auto-Immune Disease

Cancer

Diseases of the intestine/colon/hemorrhoids

Other (please specify)

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* Did you have any surgeries and when?

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* Family Health History: Please indicate any repeating chronic diseases in the family history (Cancer, Type2 Diabetes, Hypertension etc..)

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* Dietary Habits: Do you prefer animal-based diet? Love desserts? etc.

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* Medications you use (Drugs that you take from time to time or on an ongoing basis)

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* Supplements, Herbs, Homeopathics etc..

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* How often do you consume caffeinated drinks like tea, coffee or coke?

Everyday

4-5 times in a week

2-3 times in a week

Never

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* Do you drink alcohol?

Everyday

4-5 times in a week

2-3 times in a week

Never

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* Do you smoke?

Everyday

4-5 times in a week

2-3 times in a week

Never

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* How many hours do you sleep in average?

Less than 5

5-8

More than 8

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* Do you generally have problems falling asleep?

Yes

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* Do you generally have problems getting out of bed?

Yes

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* How do you generally feel in the morning?

Rested & Refreshed

Tired

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* How often do you exercise?

Almost Every Day

Once in a week

Very rarely

What kind of exercise do you do?

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* Do you have anything else, you would like to tell us regarding yourself?

We strongly suggest you do a pre-detox before arriving at our center. For more information : PRE DETOX INFO KIT

Please e-mail your current doctor reports and relevant test results to our center before your arrival.