Yoga Holidays & Retreats with Debbie Avani & Clare Harford


 

Health Questionnaire

It is important that we are aware any conditions you may have at the present time to ensure your well-being and safety. Be assured this information will remain strictly confidential and will be accessible only to Debbie and Clare.

Please complete the following giving details where necessary or answering No if not applicable

Your Name:

Email Address:
Heart condition:
Any history of heart attack, angina, operations etc.
No Yes
Kidney problems:
No Yes
High blood pressure:
No Yes
Low blood pressure:
No Yes
Abdominal surgery:
No Yes
Back or spine problems:
No Yes
Asthma or respiratory problems:
No Yes
Anxiety or depression:
No Yes
Chronic fatigue or ME:
No Yes
Eating disorder:
Historical or current
No Yes
Digestive disorder:
Historical or current
No Yes
Hyper acidity (reflux):
No Yes
Diabetes:
No Yes
Headache or Migraine:
No Yes
Allergies / Hayfever / Sinusitis:
No Yes
Pregnant:
No Yes
Next of Kin:
Please enter a name and contact phone number
I declare the information I have given is true and correct
I have been fully informed about contra-indications and am therefore willing to proceed.