The Village

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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

Title:Mr./Mrs./Ms.

First Name:*

Last name:*

Birth Date:*

Email address:*

Phone number:

Country:

Arrival date:*

Departure date:

Number of Guests:

Please give me a call:

Yes

Clients Vital Information

What Is Your Blood Pressure/ Pulse Left Side:Systolic/ Diastolic/Pulse

What Is Your Blood Pressure/Pulse Right Side:Systolic/ Diastolic/Pulse

Respirations:Number of Times in One Minute

Saliva pH:pH Range

Urine pH:pH Range

Basel Temperature:Degrees Celcius

Health History

Genetic / Family Medical History:(List the health issues each family member had, including Grand Parents both sides)

Personal Medical History:

Injuries and Operations:

Chemical Non-Prescription Medications / Quote Times and Dosages. Reason for taking?:

Natural Prescription Supplements / Quote Times and Dosages. Reason for taking?:

Have you done or are you currently in treatment:

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

If any of the above, describe and when last taken?:

Important Health Questions

Females Only

Males Only

Part 4b: / Tick the boxes if yes

I have testicular hypertrophy. Increase in volume.

I have a low sex drive.

I have an excessive sex drive.

I have erection problems.

I have premature ejaculation.

Do you have prostatitis (swelling and inflammation of the prostate gland)? (Frequent urination, especially at night? If yes, how often do you urinate?:

Do you have prostate cancer? What are you PSA counts?:

Gastro Intestinal Tract

Liver / Gallbladder / Blood

Heart and Circulation

Part 7: / Tick the boxes if yes

I get chest pains or angina.

I had a heart Attack (myocardial Infarction).

I had an open heart surgery.

I have a heart murmur or Mitral valve Prolapse.

I feel pressure on my chest.

I had high blood Pressure (Kidneys).

I have a pacemaker.

I have stints.

Do you have heart arrhythmia's? What Kind, to slow, to fast, irregular?:

Do you get prickly pains, anywhere? especially in the heart area? Where?:

Skin

Part 8: / Tick the boxes if yes

I get or had skin rashes.

I get skin blemishes.

I have eczema or dermatitis (Inflammation of the skin).

I have psoriasis (Raised red plaques covered with white scales).

My skin is dry.

My skin is excessively oily.

I get or have dandruff.

Do you itch anywhere? Where?:

Do you have skin problems? If so, what type?:

Lymphatic System

Kidney and Bladder

Lungs

Environmental Toxins

Part 12: / Tick the boxes if yes

I have been vaccinated.

I had shots for traveling to foreign countries.

I had flu shots.

I have mercury amalgams.

I find it difficult to take deep breaths.

Have you had radiation? Chemotherapy? If so, how many treatments?:

Have you been exposed to nuclear wastes or by-products, heavy metals or chemicals?:

Do you have any allergies? (Food, chemicals, etc...):

What are your major health complaints and concerns? Are there any not covered in this questionnaire?:

Describe your professional life, do you like it, love it, or are in need of a change?:

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.

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