Questionnaire
Anti-Aging-Plan.com

Life extension and
disease treatment through
periodic fasting and
caloric restriction -
the most powerful
scientifically proven
natural anti-aging method

 
Calculate your BMI
(Body Mass Index)

BMI Categories:
Underweight = <18.5
Normal weight = 18.5-24.9
Overweight = 25-29.9
Obesity = BMI of 30 or greater

METRIC STANDARD
Your Height: cm
Your Weight: kg
Your BMI:

 

Health Questionnaire and Pre-Reservation Form
(without obligation to reserve right now by filling out this form)

PERSONAL DETAILS
* Denotes mandatory fields.

First Name*
Last Name*
Address 1*
Address 2
Zip/Postal code*
City*
State/Province*
Country*
Day Phone*
Mobile Phone*
Skype
E-mail*
Weight*
Height*
Age*
Profession/Occupation
Male Female Gender

Choose from the list the diseases that you have already had or are predisposed to:

(This health questionnaire should be filled out in collaboration with
your personal physician)

bronchitis  
asthmatic bronchitis  
bronchial asthma  
tonsillitis  
maxillary sinusitis  
coronary heart disease  
angina pectoris  
atherosclerosis  
trombophlebitis  
hypertension (point pressure values)
ulcer  
gastritis (hyperacid, normacid, anacid)  
cholecystitis  
colitis  
enterocolitis  
chronic pancreatitis  
chronic hepatitis  
hemorrhoids  
pyelonephritis  
glomerulonefritis  
nephrostone disease  
radiculitis  
arthritis & polyarthritis  
articular rheumatism  
arthritis uratica  
osteochondrosis  
osteoporosis  
diabetes, compensated, II type  
neurosis – indicate diagnosis
thyroid gland disease (point out the character of dysfunction)
anemia (point the origin)
cutaneous diseases (of what kind)
allergy (point the causation factor if you know it)
other diseases:

 

Which diseases have you previously suffered from, and when?
Do you have previous experience of fasting? If so, please give us some feedback of your experience, we especially interested in how long you fasted (1 day, 3 days, week etc.) How regularly (every month, twice a year, only once etc.) Wheather you found it easy or difficlut, and what benefits or problems you found.
Location:

Type the date when you will arrive (we are open the whole year)

Check-in date: (dd/mm/yy)
Check-out date: (dd/mm/yy)

Choose the number of days you will stay with us:



What type of accommodation and services do you require?*
(This will help us to serve you better and to quote you an appropriate price)
Standard
Budget
Budget self catering
e-Diet
Want to know more about program options? Go here

We will confirm the booking by sending you a fax or an e-mail message.
If accommodation is not available for the date you have requested we will offer you an alternative date. If this new date is not acceptable to you we will cancel your booking and refund your payment.

Additional comments, special requirements:

How did you find out about our anti-aging program?

Your Certification Is Required to Process this Form:

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