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1 PERSONAL DETAILS
Name:
Date of Birth:
Email address :
Mobile telephone number:
O
ccupation
:
Height
:
Weight
:
Sex: Female
Male
What size T shirt would you like?
Small
Medium
Large
X-Large
(the T shirt shape is quite fitted)
Date of Travel :
Person to contact in case of emergency:
Name:
Telephone:
Mobile:
2 TRAVEL DETAILS
Are you travelling on our recommended flights?
Yes
No
Please specify your outgoing flight details including flight number, departure and arrival times *
Please specify your return flight details including flight number and departure time*
*For UK weekends, please apply train times
Travel insurance details
Insurance company name:
Insurance policy number:
Insurance company emergency telephone number:
3 MEDICAL DETAILS and PHYSICAL ACTIVITY READINESS
This section of the form has been designed to identify anyone for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them.
Has your doctor ever said you have heart trouble?
Yes
No
If so please specify:
Do you ever have pains in your heart and chest?
Yes
No
If so, please specify
Do you ever feel faint or have spells of dizziness?
Yes
No
If so please specify
Has your doctor ever told you that you have a bone or joint problem, such as arthritis that has been aggravated by exercise, or might be made worse with exercise?
Yes
No
If so please specify
Do you suffer from any problems of the lower back
Yes
No
If so please specify
Are you currently taking any medications?
Yes
No
If so please specify
Do you currently have a disability of a communicable disease?
Yes
No
If so please specify
Do you have any other medical issues or injuries that you should inform us about
Yes
No
If so please specify
Is there a good physical reason, not mentioned here, why you should not follow an activity programme even if you wanted to?
Yes
No
If so please specify
4 YOUR CURRENT ACTIVITY PROGRAMME
Describe your fitness level and any current form of exercise.
Have you practised yoga?
Yes
No
If so, how long for and which style(s) have you been practising, including the names of any teachers you have been working with
What level would you consider yourself to be?
Beginner
Intermediate
Advanced
What pressure of massage do you prefer?
Soft
Medium
Firm
Are there any particular areas you would like our massage therapy to focus on, or to avoid?
Please note massages are not available on UK weekends.
5 DIET
Do you eat...
fish?
poultry?
Do you have any other special dietary requirements?
Yes
No
If so, please specify.
How many units of alcohol do you consumer per week?
Do you smoke?
Yes
No
If so, how many cigarettes per day?
Any additional information?
6 AIMS AND EXPECTATIONS
What are your health aims for your time at
in:spa
?
* Please tick here to confirm that you have read, understood and answered all questions to the best of your knowledge
Many thanks for your time
