Health and Fitness Profile. Help us ensure your trip is perfectly suited

1. Personal Details

Name*

Date of Birth*

Email*

Street Address Address Line 2 City State / Province / Region Post Code Country

Home Address

Mobile telephone number*

Occupation

Height

Weight

Sex

Male
Female

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
Not yet decided

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Please provide details of your departure flights.

Departure Flight Number*

Date*

Departure Time*

: HH

MM

Arrival Time*

: HH

MM

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Please provide details of your return flights.

Return Flight Number*

Date*

Departure Time*

: HH

MM

Arrival Time*

: HH

MM

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We strongly recommend that you have comprehensive travel insurance.

Insurance company name

Insurance policy number

Insurance company emergency telephone number

4. Medical details and physical activities 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

Heart Condition Details

Do you ever have pains in your heart and chest?

Yes
No

Pains in heart/chest details*

Do you ever feel faint or have spells of dizziness?

Yes
No

Dizzyness Spell Details*

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

Joint/Bone Problem Details*

Do you suffer from any problems of the lower back?

Yes
No

Lower Back Problem Details*

Are you currently taking any medications?

Yes
No

Medication Details*

Do you currently have a disability or a communicable disease?

Yes
No

Disability/Communicable Disease Details*

Do you have any other medical issues, allergies or injuries that you should inform us about?

Yes
No

Other Medical Issues/Injuries/Allergies Details*

Is there a good physical reason, not mentioned here, why you should not follow an activity programme even if you wanted to?

Yes
No

Other reason to not follow programme Details*

5. Your current activity programme

Describe your fitness level and any current form of exercise.

Have you practised yoga?

Yes
No

What level would you consider yourself to be?

6. Diet

Weight Aims

Do you eat fish or seafood?

Yes
No

Do you eat Poultry?

Yes
No

Do you have any allergies?

Yes
No

My Allergies

Do you have any other special dietary requirements?

Yes
No

Other Dietry Requirements

How many coffees/teas do you drink per day?

How many units of alcohol do you consumer per week?

Do you smoke?

Yes
No

Number of cigarettes per day

Additional Dient Information

7. Aims and expectations

Health aims at in:spa

Please confirm that you have read and understood the Booking Terms and Conditions.*

I confirm

Read our Booking Terms and Conditions.

Please confirm that you have read, understood and answered all questions to the best of your knowledge*

I confirm

We are really careful with your data. We’re asking for this information so that we can brief the team about the group that they will be looking after so that they can prepare for the week in the best way possible. Please feel free to tell us anything that will help us ensure we provide you with the best possible holiday experience. Any data you share will be retained in line with our privacy policy. Please do not disclose anything sensitive to us on this form if you would not want us to store it.

Comments

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Health and fitness profile