HEALTH QUESTIONNAIRE

This information is to allow us to best support you during the retreat, but please note that if you have concerns about practising movement or attending a sound bath you must seek guidance from your medical provider/s. Your information will be keep securely and confidentially and only used for the reason stated above. If you would prefer to complete a paper form please let us know.

Name

First Name

Last Name

Email

Phone

(###)

###

####

Emergency Contact

Please give the name and number of your emergency contact and your relationship with them.

Do you have any of the following conditions (tick any that apply)?

Heart Condition

High or Low Blood Pressure

Stroke

Cancer

Severe Mental Health

Are you currently taking anti-depressants?

It is not advised to consume cacao if you are taking any anti-depressant medication.

Are you pregnant?

Please list any current health conditions you're currently experiencing that you feel may impact on your movement

I understand that it is my responsibility to practice movement safely and mindfully and within my current physical capabilities to avoid injury, and no healthcare professional has advised me against practising yoga or attending sound baths.

I understand