Health & Wellbeing Questionnaire
Welcome to Karme Choling! To help us support you during your time here, please complete this questionnaire. The information you provide in this form is confidential and available only to the KCL HR Director, KCL Residency Coordinator, and your meditation instructor (if relevant), so they can skillfully maintain awareness of your wellbeing.
Name
First Name
Last Name
Arrival Date
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Month
-
Day
Year
Date
Departure Date
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Month
-
Day
Year
Date
Program Name
Have you been vaccinated against Covid-19?
Yes
No
Do you have any physical limitations you would like us to be aware of?
Please list all prescription medications you are currently taking or have taken in the past six months.
Do you have any serious health conditions, such as LIFE-THREATENING allergies or other health concerns?
Do you have a weakened immune system or environmental sensitivities?
Do you need any accommodations for a disability? If so, please describe.
How can we best contact you in an emergency (i.e. cell phone number)?
Do you have any other issues or concerns you would like our Health and Wellness team to be aware of?
Do you have health insurance or traveler's health insurance?
If you are taking prescribed medications for any reason, it is crucial that you continue to take them during your stay at Karme Choling. Meditation is never a substitute for medically-prescribed medication.
Signature
Date of Signature
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Month
-
Day
Year
Date
Emergency Contact Information:
Emergency Contact's Name
First Name
Last Name
Emergency Contact's Relationship to You
Emergency Contact's Phone Number
Please enter a valid phone number.
Submit
Submit
Should be Empty: