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Health Declaration Form

Please fill out the following form to help us understand your physical condition.

First Name

Email Address

Last Name

Date of Birth

Have you been hospitalised in the last 12 months? *

No

Yes

Are you currently suffering from a medical condition, illness, or injury that may affect your ability to participate in gentle exercise? *

No

Yes

If you answered yes to any question, please elaborate. Please consult with a medical professional if you have any doubts about your ability to take part.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

© 2019 MINDFUL BODY

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