Health Declaration

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Full Name

ID Number

Date Of Birth

Mobile Number

Profession

Address

Please select the appropriate answer

Back problems / joint problems

Yes No

If so, please elaborate:

Blood Pressure:

High Low Normal

Getting treatment:

Yes No

Migraines / headaches:

Yes No

Fever / flu / infection:

Yes No

Asthma:

Yes No

Fungal infection:

Yes No

Pregnancy:

Yes No

If the answer is yes, please indicate how many weeks pregnant are you.

Cancer:

Yes No

Allergies:

Yes No

Diabetes:

Yes No

Operations / fractures / accidents in the last year:

Yes No

If your answer is yes, please indicate:

Regular use of medications:

Yes No

If your answer is yes, please indicate:

If there is a place on your body that requires my special attention?

Thank you for your cooperation

I declare that I am in good physical condition and do not suffer from any diseases, medical or otherwise, which may be affected by the treatment at Vasil Clinic. If I have consumed alcohol before or during my visit to Vasil’s clinic, I declare that I will not have any complaints and I will not prosecute the spa and its owners for any damage caused by intoxication.

By clicking "Agree", I confirm this declaration about the state of health and that all noted is true.

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Swedish Massage
Aromatherapy
Deep Tissue Massage
Orthopedic massage – Myofacial
Health Declaration
FAQ
About
Contact Us

Swedish Massage
Aromatherapy
Deep Tissue Massage
Orthopedic massage – Myofacial
Health Declaration
FAQ
About
Contact Us

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Health Declaration

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