Health Assessment "*" indicates required fields Step 1 of 10 10% Before Starting Please provide us with the following information:Privacy & Care* All information shared is treated with absolute confidentiality and is used solely to create your personalised wellness journey.Name*Last name*Telephone numberNationality* AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Age Range*Please provide us with the following information Under 30 30-39 40-49 50-59 60+ Gender Male Female I'd rather not share Preferred Language of Communication English German Thai Other Preferred destination Aleenta Phuket-Phang Nga Aleenta Hua Hin-Pranburi Aleenta Chiang Mai What is the main reason you are considering a wellness retreat at this time? (Select up to 3) Stress, burnout, or emotional fatigue Weight management Detox & gut health Hormone balance Longevity & healthy ageing Pain management Fitness & performance Mental clarity & emotional reset Sleep optimisation Recovery after illness or surgery Spiritual growth & self-enquiry Preventative health screening I’m not sure – I’d like expert guidance How would you describe your current health and energy levels? Excellent – proactive optimisation Good but I want improvement Frequently tired or stressed Experiencing ongoing symptoms or imbalance Recovering from a health issue Other Do you have any of the following? (Check all that apply) Hormonal imbalance Thyroid condition Diabetes / prediabetes High blood pressure Digestive disorders Autoimmune condition Chronic pain Cancer history Cardiovascular condition Mental health challenges None Prefer to discuss privately Are you currently under medical supervision? Yes No Have you attended a wellness or medical retreat before? First-time guest Occasional retreat guest Experienced medical-wellness guest High-performance optimisation client What best describes your ideal experience? Gentle, restorative & nurturing Balanced wellness with structure Intensive medical-wellness optimisation Psychological & emotional work Physical challenge & movement-based Integrative (mind, body & medical) Therapies & Activities of InterestSelect all that appeal to you Medical diagnostics & longevity testing Detox & gut reset IV therapy & biohacking Qigong / breathwork Sound healing Fitness & strength training Muay Thai / boxing Cycling / hiking / nature immersion Psychological coaching / rewriting experience Traditional spa & healing therapies Nutritional therapy & functional nutrition Sleep therapy & recovery What is your preferred retreat duration? 3-4 Nights 5-7 Nights 8-10 Nights 10+ Nights I'm flexible Preferred month(s) of travelBudget Range (per person, per night)This helps us match programs accurately. THB 15,000 – 25,000 THB 25,000 – 40,000 THB 40,000 – 60,000 THB 60,000+ Prefer not to disclose Accommodation Preference Private pool villa Ocean/sea-view suite Garden or nature view Best available within my program Will you be travelling: Alone As a couple With friends With family Structure vs FlexibilityWhich do you prefer? Fully structured daily programme A balance of structure and free time Mostly free time with selected sessions Completely tailor-made PersonalisationWould you like a standard retreat recommendation or a fully tailor-made program? Recommend the best existing AYURAH retreat for me Design a fully personalised retreat for me Not sure – please advise Dietary Preference Plant-based Pescatarian Mediterranean Ayurvedic-inspired No specific preference Other Food allergies or sensitivitiesIs there anything else you would like our medical-wellness team to know? Consent* I consent to being contacted by the AYURAH Wellness team for personalised retreat consultation.Consent* I understand that this assessment does not replace medical diagnosis.Consent* I accept Aleenta Privacy and Cookies policies
