Spa Client Medical History
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Room Number
Email Address
Phone Number
Medical Information
Are you currently under medical treatment?
Yes
No
If yes, please specify
Do you have any allergies?
Yes
No
If yes, please specify
Conditions (Check all that apply)
Heart Condition
Diabetes
Pregnant
High Blood Pressure
Low Blood Pressure
Skin Condition
Epilepsy
Asthma
Recent Injury
None
Other medical conditions or concerns
Current Medications
Please list any medications you are currently taking
Consent
I confirm that the above information is accurate and complete to the best of my knowledge.
Signature
Date