Date of Birth

Email

Telephone

Emergency contact (name & telephone)

Occupation

Any thing else you would like to share about your health?

Are you taking any medication (prescribed or over the counter)? If so what are you taking?

Have you had any operations? Please give details and dates

Do you currently have any injuries? If yes, please explain:

Are you pregnant? If so, how many weeks? Is this your first child? NB: Please check with your doctor that it is OK for you to do Yoga..

What is your yoga / meditation background and how long have you been practising?

What is your knowledge of energy work and / or Energy Medicine Yoga? 0-10

On a scale of 1-10, how physically active is your lifestyle currently (10 being the most active)?

How did you hear about the retreat?

Any concerns about the retreat?

Retreat Health Form