Spa Questionnaire

Are you taking any medication? *

If yes, please provide brief details

Are you currently under any medical supervision? *

If yes, please give details below

Please tick all that apply

Stroke/DVT

High/low cholesterol

Liver or kidney problems

Asthma/lung condition

Eczema/ Psoriasis/ Skin condition

Arthritis/ Rheumatism

IBS/ Bowel condition

Other medical conditions

If yes, are you in your:

First trimester

Second trimester

Third trimester

Are you breastfeeding? *

Have you had any operations or cosmetic procedures in the last six months? *

If yes, please give details

Do you have any areas or pain / inflammation / bruising

What is your stress level?

How many days a week do you exercise?

I understand that treatments are only suitable for over 18s unless stated otherwise.

Treatment disclaimer *

I understand that Donnington & Co Health Club and Spa have a 24 hour cancellation policy on all treatments and Spa Days. If I do not give 24 hours notice of my cancellation, I will be charged in full.

Treatment cancellation policy *

I can confirm that I am not having any spa treatment against medical advice or instruction and all of the above information is a full and accurate statement of my current physical and mental status.

Treatment Disclaimer *