Name *

First Name

Last Name

Phone *

(###)

###

####

1) Do you have a history of, or currently suffer from any of the following: *

a) Cardiovascular disease, including heart attacks

Yes

No

b) High blood pressure *

Yes

No

c) Severe mental illness *

Yes

No

d) Recent surgery

Yes

No

e) Past or recent physical injuries, including fractures or dislocations *

Yes

No

f) Recent or current infectious or communicable diseases *

Yes

No

g) Glaucoma *

Yes

No

h) Retinal detachment *

Yes

No

i) Epilepsy *

Yes

No

j) Osteoporosis *

Yes

No

k) Asthma (if “Yes,” please bring your inhaler to workshop) *

Yes

No

2) Are you currently pregnant? *

Yes

No

3) Have you ever been hospitalized for medical reasons? *

Yes

No

4) Have you ever been psychiatrically hospitalized? *

Yes

No

5) Are you currently in therapy or involved in any type of support group? *

Yes

No

6) Are you currently taking any type of medication? *

Yes

No

7) Were there any complications at your birth? *

e.g. Caesarean section/Anesthesia

Yes

No

8) Is there anything else about your physical or emotional status of which we should be aware? *

Yes

No

Date Signed *

MM

DD

YYYY