Health Declaration Form

Health Declaration Form

Please reach out if you have any questions: bek.wellness@gmail.com
Do you have a history of cardiovascular illness?
Do you have a history of epilepsy?
Do you have a history of, or are you experiencing significant mental/emotional instability?
Are you, or is there a chance you might pregnant?
Do you have any other conditions that may prevent your participation? (medical, traumatic, medications, injuries, recent surgeries, etc)? In the case that you are unsure, please check yes to confirm suitability with your facilitator.
If you answer "YES" to one or more questions, please check with your doctor to clarify if you're capable of doing physical activities, and deep rhythmic breathing.

If you have any questions about any of this, or woould like to discuss anything relating to your situation, please don't hesitate to email me at: bek.wellness@gmail.com
Personal Information
Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Person

First NameLast Name
Emergency Contact Person No.
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
Date
Should be Empty:

Personal Information