MEDICAL INFORMATION

New Life Spa and Wellness Centre
Personal Information
Name
Home Address
Preferred Contact Number
Date
Email Address
Age Group
Kindly Indicate - 20 to 30, 30 to 40, 40 to 50, or 60 Plus
Lifestyle?
Sedentary, Semi Active, Active
MEDICAL INFORMATION
Doctor's Name and Address
If you have any health condition (weather or not listed below) we recommend that you only proceed with your doctor's permission.
Date of Last Period (If Applicable)
Any Gynecological Issues?
Irregular Period - P.M.T - Menopause - H.R.T - Pill - Coil - Other
Pregnant? 1st, 2nd, 3rd Trimester?
Any Recent Operation? Last 6 Months
Type Yes or No. If 'Yes' Kindly Specify
Any Arthritic Conditions?
Kindly Specify Where and Type
Any Cardiovascular Conditions?
Heart and/or lung associated.
Are You Diabetic?
If Yes Indicate Type 1 or Type 2
Any Sunburn?
Kindly Specify Where, Even If It's Minor
Any Skin Allergies?
Kindly Specify If Receiving Body Scrub or Facial
Product Allergies (Eg: Coconut)
So your therapist knows what massage oils to avoid.
Any Generalized Inflamation?
If 'Yes' Kindly Indicate So Your Therapist Is Aware
If Yes. Where?
Eg Elbows, Knees, Fingers, Toes.
Any Localized Swelling?
Hands, Knees, Feet? If inflammed massage would not be recommended or the area will be avoided.
Nervous System
Migraines - Tension - Stress - Depression
Any Other Medical Condition?
Eg: Conjunctivitis - Pinched Nerve - Inflamed Nerve - Watery Eyes - Eye Infections - Acne - Hypersensitive Skin - Kidney Infection - Thyroid Problems - Liver Problems - Hernia
Antibiotics/Medications?
Herbal Remedies/Supplements?
Kindly Specify
What Is Your Ability To Relax?
Good - Moderate - Poor
What Is Your Preferred Pressure?
Light - Moderate - Deep - Adjustable
Is there anything that may affect or prevent you from having a treatment?
Indicate 'Yes' or 'No'
Any areas that you prefer we concentrate on or spend more time on?
Eg: Neck, shoulders, back, feet
Any areas to be avoided?
Eg: Neck, shoulders, back, feet
What Do You Expect From Your Session?
SECURITY NOTE

Once you are having the treatment(s) make sure you are okay with this and sign. Please read carefully and sign only if you are in full agreement with the contents
I confirm that I have understood the treatment that I am to receive and confirm that I am willing to proceed without confirmation from my own General Practitioner or Consultant.

LIABILITY RELEASE, ACKNOWLEDGEMENT AND WAIVER

I the undersigned, understand, acknowledge and agree that: (1) I am aware that the facilities/services involve risks, included but not limited to, risk of bodily injury or death: (2) I have provided the relevant information regarding my medical history and health condition: (3) I am making use of the facilities/services of my own free will; and (4) I assume all risks associated therewith. On behalf of myself and heirs I hereby release and discharge the entity that operates New Life Spa and Wellness Centre and all the affiliates, subsidiaries, employees, agents, landlords, representatives, successors and assigns from any and all claims or causes of actions arising out of or related to my use of the facilities/services of that entity, including but not limited to those resulting from death or theft, loss or damage and without limiting or affecting any statutory rights I may have.
Guests Signature
Date

MonthDayYear
Date
Therapists Signature
Should be Empty:

SECURITY NOTE