Full Name:

Room number:

Nationality:

Age:

General Information

Type Treatment Date
Dermatitis:
Inflammation:
Infection:
Allergies:
Cancer:
Recent Surgery:

Cardiovascular concerns:

Muscle- sceletical concerns:

Phlebitis (stage):

Anti- coagulant treatment:

Medicine on regular basis (type):

Metallic implements:

Other:

Female Information

Pregnancy (date):

Menopause (date):

Physical activity:

Which area would you like the treatment to concentrate on :

Which area would you like the treatment to avoid :


The Althea Spa reserves the right to deny offering its services to guests with certain medical conditions based on our spa manager judgment .

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