1. Personal Information
Full Name
First Name
Last Name
Birthday
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Height (cm)
*
Weight (kg)
*
Clothing size
Shoe size
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2. Medical Information
Care card #
I have a private insurer
Insurance company
Policy Number
Authorization Number
State of physical condition
Excellent
Good
Average
Poor
Medical History (please check all that apply)
Any surgery within the last 5 years
Allergies
Epilepsy
Any circulatory problems, Thrombosis etc.
Visual acuity (need for glasses or contact lenses)
Major illness / disability
History of joint injury or related chronic problems
Are you pregnant?
Are you currently taking any form of medication?
Please give further detail if you have selected any of the above
Do you suffer from any of the following (please check all that apply)
Disorders of the Nervous System
Behavioural concerns
Phobias
Please give further detail if you have selected any of the above
In case of emergency, please contact
Name
Phone Number
Name
Phone Number
Name
Phone Number
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3. How do you like your food and drinks to be prepared
Our ideal breakfast in the morning would be
What we like eating the most is
We like our meals to be accompanied with (drinks)
A perfect cocktail would be
We definitively don’t like to eat
Do you like to eat spicy food?
A little bit
Normal
Very spicy
No, thank you
Any dish that you crave for?
Do you eat deer meat or lamb?
Please Select
Only deer
Only lamb
Both
None
Other
Other option
Do you eat food with garlic and/or onion?
Please Select
Only garlic
Only onion
Both
None
Do you like to eat mayonaise?
Please Select
Yes
No
Other
Other option
What kind of milk do you like to drink? (almond, rice, soy, etc)
Do you like sugar? or do you prefer a sweetener (what kind of sweetener)?
What kind of dessert(s) would make you happy?
For further comments or suggestions in regards to the preparation of your meals & drinks,please let us know in the box below:
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4. Describe your ideal holiday experience
The perfect day we imagine in Pucón includes the following activities:
Our favorite excursion(s) would be
Any particular reason or special occasion for your visit?
Any special interest or activity you wish to experience?
Might there be something else you wish to tell us regarding the excursions and activities?
Would you like to do yoga class?
How often and what type of yoga do you prefer?
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