Confidential Information
The following confidential information will be treated with strict confidence. The information is required for your safety and to benefit your health. There may be certain contraindications, which will require special attention and/or further discussion. It may be necessary to consult with your Medical Practitioners before the start of any of our retreat or online programs.

Take your time to fill out this health Questionnaire with complete honesty, a thorough health screening can help us to personally tailor together the most efficient retreat or online wellness program.

Your Details

Clients Vital Information

Health History

Intake of Stimulants or Depressants:

Intake of Stimulants or Depressants, Opiates (Drug derived from opium, psychoactive compounds such as morphine, codeine, thebaine), Hallucinogenic (Psychedelics, dissociative, deliriant), Benzodiazepine These are sedatives, hypnotics (sleep inducing), anxiolytic (anti-anxiety) anticonvulsants and muscle relaxants. (Psychoactive drugs such as chlordiazepoxide (Librium) or Diazepam (Valium)), Cannabinoids Most notable is tetrahydrocannabinol (THC), Solvents (Distinct chemical liquid, solid or gas), Amphetamines (Stimulants, empathogens, hallucinogens), Alcohol , Nicotine. Others

Important Health Questions

Females Only

Males Only

Gastro Intestinal Tract

Liver / Gallbladder / Blood

Heart and Circulation


Lymphatic System

Kidney and Bladder


Environmental Toxins

At The Spa Resorts, we are committed to safeguarding your privacy. Prior to submitting the form, please take some time to read our Privacy Policy, and make sure you are happy with our use and storage of your personal information.

Privacy Policy*

Please read and accept the Privacy Policy