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Health Form
New Customers Health Form
NEW OR RETURNING CUSTOMER HEALTH FORM
First name
Last name
Email
Date Of Birth
GP, NAME & ADDRESS
Are You Taking Any Medication?
Please list any allergies.
Please give details of recent and relevant medical treatment, operations or family history
Do you have Epilepsy?
Are you pregnant or trying to be pregnant?
Please list any past or current injuries.
please tick if applies to you:
*
Required
Deep Vein Thrombosis
Wounds/Healing
Acute inflammation/tumours
Recent surgery
Eczema
Skin Disorders
Pacemaker/heart contiditions
Shunt
Stent
Whiplash in the last 3 days
None Of The Above
I confirm that what I've shared is correct
Your Signature
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Date signed
please share what you'd like to focus on:
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Required
Better Sleep
Reduce Stress
Create More Joy
Improve Health
Pain Reduction
Spiritual Connection
Improve Diet/Weight
Healing From Trauma
Relax
Improve Fitness
How are you in general, please note energy levels, emotional state or physical ailments.
I understand that I am responsible for my own health and safety when attending a practice with Josephine at Echo Yoga and Sound, I have disclosed all relevant information to Josephine before attending
Date signed
Your Signature
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