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WILD RETREAT AT CABILLA CORNWALL
Yoga Day Retreat in Berkshire
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YOGA DAY RETREAT HEALTH QUESTIONNAIRE
Name
*
First
Last
Email
*
Phone
*
Emergency Contact Name
*
First
Last
Emergency Contact Phone
*
Have you done yoga before?
*
No, never
Yes, but a while ago
Yes, but not regularly
Yes, I'm currently practicing
If Felicity doesn't already know your practice, please give details about your experience of yoga (e.g. years practicing, type of yoga and regularity)
Do any of these health conditions apply to you?
High blood pressure
Low blood pressure / fainting
Arthritis
Diabetes
Epilepsy
Heart problems
Asthma
Depression
Anxiety
Detached retina /other eye problems
Recent fractures /sprains
Recent operations
Back problems
Knee problems
Neck problems
Hip problems
Carpal Tunnel Syndrome
Sciatica
Recent pregnancy (how many months postnatal?)
Currently pregnant (how many weeks?)
Currently undergoing fertility treatment
Other conditions (please state below)
Please give details about the conditions above (if applicable)
Please give details of any allergies that you have (if applicable)
Please give details of any dietary requirements or preferences that you have (if applicable). All meals on the retreat will be vegetarian, low in gluten and refined sugar. We can cater for any special diets.
Please read the following and confirm
*
I confirm that, to the best of my knowledge, these answers are accurate and I know no reason why I should not participate in a yoga retreat. I acknowledge that all physical activities involve risk of personal injury and I agree to take responsibility for my health and wellbeing, including any injuries during the yoga classes. I will inform my yoga teacher of any medical changes.
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