Full Name: *
Nickname:
Date of Birth / Age: *
Gender: *
MaleFemale
Phone / WhatsApp: *
Nationality:
Preferred Language: *
EnglishIndonesianOther
If Other, please specify:
Why are you joining this wellness activity? (You may select more than one)
Relaxation & stress reliefReduce body/muscle/joint painImprove sleep qualityImprove fitness & body balanceSupport recovery after illness/surgeryOther
High blood pressureLow blood pressureHeart diseaseStroke/TIADiabetesAsthma/lung diseaseHigh cholesterolOsteoporosisArthritisOther
If yes, please explain:
Medications taken daily:
Allergies:
NoneMedicationFoodOther
If Medication, please specify:
If Food, please specify:
Assistive devices:
CaneWalkerWheelchairOther
Daily activity level: *
Fully independentNeeds minimal helpNeeds full assistance
Walking without stopping: *
< 5 min5–15 min> 15 min
Standing without sitting: *
Do you feel:
Easily tired during light activity.
YesNo
Afraid of falling due to weak balance?
Body areas with frequent pain:
NeckShoulderBackWaistHipKneeAnkleOther
Have you fallen in the past 6 months? *
Has your doctor given restrictions on exercise? *
NoYes
If Yes, details:
Activities you are interested in (choose any):
Gentle senior yogaLight stretchingBreathworkGuided meditationNature walkHealth educationOther
Activities you find difficult or uncomfortable (ex: squatting, sitting on the floor):
I confirm that the information provided is true.
I understand this wellness program is not a medical treatment and I am advised to consult my doctor if needed.
I agree to follow instructions and inform staff immediately if I feel pain, dizziness, or discomfort.
Guest Name: *
Date: *
I agree to the terms stated above
