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Health Declaration Form

Name

Email

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

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

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

Fever

Yes

No

Dry cough

Yes

No

Cough with phlegm

Yes

No

Shortness of breath

Yes

No

Sore throat

Yes

No

Runny nose

Yes

No

Body pain

Yes

No

Diarrhea

Yes

No

Chills

Yes

No

Loss of Smell

Yes

No

Loss of taste

Yes

No

Redness of eyes

Yes

No

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: