Registration and Health Questionnaire

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Name*

Address

City

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Country*

Email*

Phone

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How did you hear about us? Brochure Web A Friend

Health Questionnaire

Heart conditions No Yes

Recent surgery No Yes

Asthma/respiratory problems No Yes

High blood pressure No Yes

Low blood pressure No Yes

Eye problems/glaucoma No Yes

Digestion Issues No Yes

Diabetes No Yes

Depression No Yes

Anxiety No Yes

Problems/injuries with the neck, spine, joints or muscles - please elaborate No Yes

Pregnancy/Childbirth No Yes

Mobility Limitations No Yes

Any other medical problems that might interfere with exercise No Yes

Dietary Questions

Please check all that apply. Use the field to the right for brief descriptions if needed.

Allergies to Food No Yes

Vegetarian No Yes

Non-vegetarian No Yes

Special dietary requirements No Yes

Please tick!  * I declare that I have disclosed on this form all relevant health and medical details which may affect my ability to perform exercise and take full responsibility for attending this Health Retreat.

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