Health Screening For Yoga
Spanish Yoga Retreat
Full Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Date Of Birth
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
What is your Gender?
*
Male
Female
Other
Check any symptoms that you may be currently experiencing:
NONE
Chest pain
Respiratory
Cardiac disease
Cardiovascular (eg high blood pressure, cholesterol)
Neurological
Psychiatric
Gastro-intestinal
Genito-urinary
Unexplained weight gain / loss
Musculo-skeletal
If you've checked any of the above please give relevant details
Are you currently taking any medication?
*
Yes
No
If "yes" please give details (eg name of drug, dosage)
Have you or your immediate family ever received a diagnosis of:
*
NONE
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Respiratory disease
Inflammatory Arthritis
Other
If so, please give details (eg diagnosis, approximate dates, current or past?)
Do you have any allergies?
*
Yes
No
Not Sure
Please give details
Are you experiencing or do you have any history of back pain, neck pain or trapped nerve (eg sciatica)?
*
Please Select
Yes
No
Please give details including approximate dates, treatments and outcome
Please verify that you are human
*
Submit
Should be Empty: