KMM Dance Retreat Health Form:
Your wellbeing is our upmost concern. Traveling to new places is always stressful on your body, and travel to developing countries can be especially taxing. Resort stays may not shelter you from the change in climate, diet, and cultural norms that are likely to put extra stress on your system and make you vulnerable to bacteria and viruses your body is not familiar with. For all these reasons it is important that you consider carefully the state of your health and make sure you carry with you all of the medication/herbs/vitamins that you may need. Please answer the following questions that are designed to give us medical and dietary information we will need if you require medical attention. We highly recommend a health checkup both before and after your trip.
Name
*
First Name
Last Name
Email
*
example@example.com
Do you currently have any illness and/infection? Please select from the below.
*
Please Select
Yes
No
Maybe
If yes, please explain.
Have you been hospitalized or had major surgery within the last year? Please select below.
*
Please Select
Yes
No
If yes, please explain.
Are you pregnant or have you given birth within the last two years? Please select.
*
Please Select
Yes
No
N/A
If yes, did you have any of the following (circle all that apply or if you are currently experiencing the below symptoms)
*
Split Abs (Diastasis Recti)
Cesearean Birth
Post Pardum Depression
Prolapsed Uterus
Bladder Incontinence
Birth Trauma
None of the above
Other
If you selected any to the above, have you fully recovered? Please explain.
Do you have a history of the following conditions? Check all that apply.
*
Diabetes
Irregular Heartbeat
Liver Disorder
Seizures
Asthma
Fibromyalgia
High Cholesterol
Emphysema
Bronchitis
Family History of Heart Disease
Depression
Smoking
Heart Attack
Kidney Disorders
Stroke
High Blood Pressure
Arteriosclerosis
Panic Attacks / Anxiety
Frequent Headaches Migraines
Difficulty Breathing / Catching Breath
Long Covid Symptons
None of the above
Other
Do you currently experience or have a history of the following injuries or orthopedic concerns?
*
Joint Issues Arthritis
Disc Issues Bursitis
Low Back Pain
Knee Pain
Sciatica Foot Cramps / Pain
Tendonitis
Ankle Sprain
Nerve Pain
Rotator Cuff Injury
Should/Neck Pain
Hip Pain
Other
None of these
If yes, please elaborate.
Do you have any other medical condition(s) or issues with a particular aspect to your health/body not previously mentioned?
*
Please Select
Yes
No
If yes, please explain.
Have you been in any accidents in the last 5 years? (Car, motorcycle, bicycle, sports, etc.)
*
Please Select
Yes
No
If yes, please explain.
Are you currently receiving any physical therapy?
Please Select
Yes
No
N/A
If yes, please explain.
Are you currently taking any medications?
*
Please Select
Yes
No
If yes, please explain.
Describe your diet type.
*
Do you have any food sensitivities or allergies? Please explain.
*
Please describe your current fitness/dance/movement activities & frequency.
*
Have you tested positive for COVID-19 within the last 3-months?
*
Please Select
Yes
No
If yes, please elaborate and speak on any long term effects or symptoms.
Is there anything else that we should know in regards to your health or wellbeing in providing you with the upmost support and care during our retreat? Please explain below.
I have answered the above questions to the best of my knowledge and have not withheld any relevant information.
We respect your privacy. Your answers will remain private and confidential.
Submit
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