Forms - AdventureYogi Health Questionnaire

Name*

First Name Last Name

Email*

Date of birth

Q1 Have you had an operation, injury, illness or any other physical condition, that requires you to be careful with movement?

No
Yes

Q2 Do you have, for any reason, limited movement, or are suffering pain. Please give a brief description.

No
Yes

If yes

Q3 Do you or have you suffer/ed any of the following?

If any of the above are current please give a brief detail

Q4 Are you under treatment by a doctor?

No
Yes

If so, please give details including medication prescribed.

Q5 Do you have current or past problems with addictions, obsessive disorders or any other difficulties?

No
Yes

Q6 Do you have your own personal Health Insurance?

No
Yes

Q7 Coronavirus: Have you had the Coronavirus?

No
Yes

If yes, when?

Q8 Have you had any symptoms of the coronavirus in the last 2 weeks?

No
Yes

Q9 Have you come into contact with anyone with a positive COVID-19 test result in the last 2 weeks?

No
Yes

Q10 Is there anything else about your health that we need to know?

Consent of service*

I accept that the services offered to me are done entirely at my own risk, including whilst being in this time of COVID-19 and AdventureYogi will not be liable for any damage, injury or illness howsoever arising. All activities and attendance on the retreat are taken under the complete responsibility of each participant. I have my own personal insurance, private travel and health insurance

Signed*

By checking this box I agree that the information I have provided is correct

18/04/2024

AdventureYogi Health Questionnaire

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