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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

No

Joint-related issues

Yes

No

Ligament injuries

Yes

No

Spinal conditions

Yes

No

Bowel/Bladder issues

Yes

No

Communicable disease

Yes

No

Chronic pain

Yes

No

Glaucoma / Retinal Detachment / Eye Surgery

Yes

No

Depression / Psychosis

Yes

No

Diabetes

Yes

No

Respiratory conditions

Yes

No

Heart Conditions

Yes

No

High blood pressure

Yes

No

Low blood pressure

Yes

No

Seizures / Epilepsy

Yes

No

Stroke

Yes

No

Bleeding disorders

Yes

No

Hernia

Yes

No

Hospitalization for a psychiatric condition in the past

Yes

No

Any Serious illness in the last three years:

Yes

No

Any Injury in the last three years:

Yes

No

Surgery in the last three years

Yes

No

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

Yes

No

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

Yes

No

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

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!