Spa Consultation Form
Teratak Spa HQ, Penang
Membership Number:
Name
*
Tan Sri
Puan Sri
Datuk
Datin
Doctor
Professor
Tuan
Encik
Puan
Cik
Salutation
First Name
Last Name
Full Name
*
Salutation
*
Datuk
Datin
Doktor
Professor
Tuan
Encik
Puan
Cik
Email
example@example.com
Facebook/IG/Tweeter/LinkedIn Address
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Call Number
*
-
Area Code
Phone Number
WhatsApp Number
*
-
Area Code
Phone Number
Birth Date
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Occupation
*
Company/Organisation
*
Do you work from home?
*
Yes
No
Marital Status
*
Married
Single
How do you hear about us:
*
Website www.teratakspa.com.my
Facebook
Instagram
Google Search
Referral
Other
If Referral please state name & contact no
Your Health
Medical History
Have you been fully vaccinated and past 14 days?
*
Yes
No
Have you been diagnosed with Covid-19 before?
*
Yes
No
Are you exhibiting fever, cough, shortness of breath or sore throat?
*
Yes
No
Body Height
*
Body Weight
*
Are you currently taking any medications?
*
Yes
No
If yes, what?
Are you currently pregnant?
*
Yes
No
Do you have a history of any of the following conditions?
*
High or low blood pressure
Cancer
Headaches/migraines
Asthma
Arthritis
Heart attack
Thrombosis
Fractured within the last year
Eczema
Varicose veins
Insomnia
Diabetes
Allergies
Birth Control Implant/IUD
None
Have you had any recent surgery, accidents or injuries?
*
Yes
No
Do you take any vitamin to other supplements?
*
Yes
No
Do you exercise on a regular basis?
Jogging
Zumba
Walking
Gym
Cycling
Yoga/Meditation
Sometimes/Never
Other
How many hours do you sleep per night?
Your energy levels:
Low
Medium
High
Your needs & expectation
*
Relaxation
Body ache & fatigue
Stress
Emotional balance
Other
Your needs & expectation
*
Relaxation
Body Ache & fatigue
Stress
Emotional balance
Wedding/Engagement Preparation
Birthday Celebration
Wedding Anniversary
Pre-Menopause/Menopause
Low Libido
Other
Have you had a professional massage before?
*
Swedish Massage
Traditional Malay Massage
Thai Massage
Balinese Massage
Never
Have you had a professional massage before?
*
Swedish Massage
Traditional Malay Massage
Thai Massage
Balinese Massage
Never
What pressure do you prefer?
*
Consent & Agreement: I confirmed that the above statements are true and correct therefore I give my consent and authorisation for my treatment to be carried out. I will be hold accountable for any injury or accident caused by my own negligence or my failure of notifying the therapist any extra ordinary situation that occurred throughout the treatment session.
*
Guest Signature
To be filled by Spa Supervisor/Therapist
Spa section
Body Analysis
Submit
Should be Empty: