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Health Declaration Form

Name

Phone

Age

Gender

Address

Workshop you are registering for

Start date

End date

I agree to provide specific health details

Any physical limitations or disabiities:

Neck / Back aches / Injuries

Yes

Joint-related issues

Yes

Ligament injuries

Yes

Spinal conditions

Yes

Spinal conditions

Yes

Bowel/Bladder issues

Yes

Communicable disease

Yes

Chronic pain

Yes

Glaucoma / Retinal Detachment / Eye Surgery

Yes

Depression / Psychosis

Yes

Diabetes

Yes

Respiratory conditions

Yes

Heart Conditions

Yes

High blood pressure

Yes

Low blood pressure

Yes

Seizures / Epilepsy

Yes

Stroke

Yes

Bleeding disorders

Yes

Hernia

Yes

Hospitalization for a psychiatric condition in the past

Yes

Have you had any of the following symptoms in the last 14 days?

Fever

Yes

Dry cough

Yes

Cough with phlegm

Yes

Shortness of breath

Yes

Sore throat

Yes

Runny nose

Yes

Body pain

Yes

Diarrhea

Yes

Chills

Yes

Loss of Smell

Yes

Loss of taste

Yes

Redness of eyes

Yes

Have you been tested positive for Covid-19 in the past 60 days? If so, what test was done and please attach the image of the lab report.

Any Serious illness in the last three years:

Yes

Any Injury in the last three years:

Yes

Surgery in the last three years

Yes

Psychotherapy, psychological therapy and counseling in the last five years:

Yes

If any of the above is selected as Yes, please give details of the nature and duration of the condition and if you are currently undergoing any treatment

H/O Smoking

Yes

H/O Drugs:

Yes

H/O Alcohol:

Yes

For women, Are you currently pregnant or planning for pregnancy?

Yes

Any other comments:

I hereby declare that the above information is true, accurate and complete to the best of my knowledge. I also assure that I am not withholding any information.

Thanks for submitting!

admin@yoga-systems.com

Jakarta

Tanah Teduh, Unit 15, Jl. Jati Padang Raya, Pasar Minggu

Bali

Jalan Mertasari, Gg 12 No. 12, Sanur Kauh, Denpasar Selatan

Health Declaration Form

​© 2021 YOGA SYSTEMS - HATHA YOGA SCHOOL

© 2021 YOGA SYSTEMS - HATHA YOGA SCHOOL