Full Name : 姓名（英） : *

Age 年龄 *

Date of birth 生日日期 *

Phone 电话号码 *

Email (if have) 邮件（如有）

This is for interview section 营养师需要跟你咨询哦

Gender 性别 *

Male 男

Female 女

Occupation 职业 *

Marital Status 情感状态 *

Single 单身

Married 结婚

Divorced 离异

Single Parent 单亲

Address 住家地址 *

Detox Program Date 排毒日期 *

Emergency Contact 紧急联系人 - Name 名字（英） *

Emergency Contact 紧急联系人- Relationship 关系 *

Emergency Contact 紧急联系人 - Contact 电话 *

Emergency Contact 紧急联系人 - Email 电邮（if have / 如有）

Emergency Contact 紧急联系人 - Address 地址

Did you come with any other person for this course 您是否和其他人一起参加这门课程： *

YES 是

NO 不是

If above answer is YES, name of the person you came with : 如果以上答案为“是”，您的陪同人员姓名：

Do you take any depression medicine? 你有服用任何抑郁症药物吗？ *

YES 有

NO 没有

If YES, provide detail eg.level (Depression) 如果有，请提供详细信息

Do you take any painkiller / antibiotics / steroids regularly? 你有经常服用任何止疼药/抗生素/含有类固醇药物吗？ *

YES 有

NO 没有

If YES, provide detail eg.level (Painkiller/Steriods) 如果有，请提供详细信息

Do you have any other sickness not mentioned above ? 你有没有其他没有提到的病以上？ *

YES 有

NO 没有

If YES, provide detail eg.level (sickness) 如果有，请提供详细信息

Daily Water Intake 每天喝水量 *

Sleep Quality 睡眠品质 *

Frequency of bowel movements 排便频率 *

Feces Shape 粪便形状 *

Have you done any detoxification program before ? 你曾经做过任何排毒吗？ *

Yes, I did 有

No 没有

If Yes, how many times? 几次？

Date of last detox : 最近一次排毒日期 :

Place of detox：排毒地点：

Have you ever fasted before ? YES / NO 你曾经禁食过吗？有 / 没有 *

YES 有

NO 没有

What is your main purpose or goal by attending this detoxification program : 您参加此排毒项目主要目的或目标是什么： *

What is your usual diet before detoxification program : 排毒前您的饮食主食是什么： *

I hereby confirm that all the information given are valid, true and complete. My participation in this retreat program at HAPPI WELLNESS SANCTUARY is by voluntarily. I will not conceal any illness and will provide any further medical record or information upon request by the center. I will take full responsibility if something happens to me during the program and I will not hold HAPPI WELLNESS SANCTUARY SDN BHD, HAPPI VILLAGE SDN BHD's management and staff responsibility. I have read and fully understand the Notice of Personal Data Processing as attached with this form and hereby confirm that any person whose personal data is given in this form has consented to the processing of his personal date for the purpose of this retreat program.

我在此确认所提供的所有资料都是有效、真实和完整的。我参与这次HAPPI WELLNESS SANCTUARY 的静修排毒项目是自愿的。我不会隐瞒任何本身有的疾病，我会应中心要求提供任何进一步的医疗记录或信息。如果在排毒期间我发生了什么事，我将不会让 HAPPI WELLNESS SANCTUARY SDN BHD, HAPPI VILLAGE SDN BHD 管理层和员工付上任何责任。我已阅读并完全理解随附的个人数据处理通知使用此表格，

并在此确认，在表格中提供其个人数据已同意出于此排毒项目的目的处理其个人日期。

Signature Name 本人姓名（英） *

IC/Passport 身份证/护照： *

Date 日期 *

Our Vision is to get you back to your full potential physical & psychological into enjoying the Joy of Living in good health. We are sharing our simple & easy way to enjoy health living and more. This can be very simple when we know the effective approach in enjoying the Joy of Living in good health.

我们的愿景是让您充分发挥身心潜能，享受健康的生活乐趣。我们分享着我们简单轻松的方式来享受健康生活。当我们知道健康地享受生活乐趣的有效方法时，这将会是简单一件事。