Wellness Registration Form (EN)

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About
Rooms
Offers
- Stay
- Wellness
Experiences
Gallery
Reservations

Wellness Questionnaire

All responses are confidential and will only be used to enhance your experience and advise you if any treatments are not medically suitable.

Full Name

Date of Birth (DD/MM/YYYY)

Sex

Height (cm)

Weight (kg)

Do you have any allergies? (Food / Drugs)

Please list current medications you are taking.

Any recent surgeries or medical treatments?

Medical History

Hypertension Diabetes High Cholesterol Heart Disease Asthma Lung Disease Stroke Thyroid Liver Disease Stomach / Colon Prostate Kidney Disease HIV Seizures Skin Blood Clots Anemia Cancer Arthritis Depression

Other Conditions / Additional Information

What are your main wellness goals?

General Health Anti-aging Wellness Skin Beauty

Experienced any of these symptoms in the last 6 months?

Weight gain Weight loss Insomnia Sleeping issues Constipation Excretory System High Stress Eating problems

Female Only

Are you currently pregnant?

Menopause?

Menstrual Period

I confirm that the information I provided is accurate and complete to the best of my knowledge. I accept all responsibilities for any harm or complications that may arise from inaccuracies or omissions in the information I provided. In the case that I am unable to proceed with the treatment and cannot arrange for an alternative treatment, I agree to pay only for the costs incurred (i.e. transportation, massage, other costs).

I accept

Submission Successful

Thank you for providing your information. Your submission has been received successfully.

PRASEBAN RESORT
173 Moo 4 Paknampran, Pranburi,
Prachuab-kiri khan 77220, Thailand.

sales@prasebanresort.com
Tel: +66 32 630 590

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