New Health and Fitness Form

New Health and Fitness form

Personal Details
Retreat*
Name*
Email*
Mobile*
Address
Street Address Address Line 2 City State / Province / Region Post Code Country
Occupation
DOB*

DD
MM
YYYY
Emergency Contact
We strongly recommend you take out private travel insurance to cover any eventuality. Please bring your policy details with you on the holiday
Emergency Contact*
Emergency contact number*
Outbound Flight Details
Outbound Flight Date*
Date Format: MM slash DD slash YYYY
Departure Airport*
Arrival Airport*
Flight Arrival Time*

: HH

MM

24 hour clock please
Airline*
Flight Number*
My choice of transport*
Return Flight Details
Return Flight Date*
Date Format: DD slash MM slash YYYY
Departure Airport*
Return Flight Time*

: HH

MM
Airline*
Return Flight Number*
My choice of transport*
Medical details and physical activities readiness
Height*
Weight*
Your Heart*
Has your doctor ever said you have heart trouble? If so, please specify
Faintness or Dizziness*
Do you ever feel faint or have spells of dizziness?
Your Back*
Has your doctor ever told you that you have back problems? If so, please specify
Medication*
Are you currently taking any form of medication? If so please specify
Disabilities*
Do you currently have a disability or a communicable disease? If so please specify
Other*
Do you have any other medical issues, (non-diet related) allergies or injuries that you should inform us about? If so, please specify
Diet
Weight aims*
Dietary Allergies*
Do you have any allergies? If yes, please specify, including severity of allergy
Dietary Requirements*
Do you have any other special dietary requirements? If yes, please specify
Coffee/tea*
How many coffees/teas do you drink per day?
Alcohol*
How many units of alcohol do you consume per week?
Smoking*
Do you smoke?
- Yes
- No
Current Activity Programme
Current Fitness Levels*
Describe your fitness level and any current forms of exercise
Yoga level*
Preferred hiking level
Aims and expectations
Aims*
What are you hoping to achieve on your in:spa retreat with us?
Confirmations
We are really careful with your data. We ask for the information in this form so that we can communicate your needs and requirements to our team of professionals who will ensure you get the very best from your retreat. We will retain your information on our system in line with our privacy policy. Please do not share anything sensitive with us if you would not want us to store it.
Booking Terms and Conditions*
Please confirm that you have read and understood the Booking Terms and Conditions
- I confirm
Understanding*
Please confirm that you have read, understood and answered all questions to the best of your knowledge
- I confirm
Number

New Health and Fitness Form

New Health and Fitness form

Personal Details

Emergency Contact

Outbound Flight Details

Return Flight Details

Medical details and physical activities readiness

Diet

Current Activity Programme

Aims and expectations

Confirmations