Mindful Yoga Jan – MindfulnessUK Portal

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Name(Required)

First Last

Phone(Required)

Email(Required)

Main presenting problem/issue, if any

Your Health

Please indicate if any of the following apply to you

High blood pressure

Low blood pressure

Recent operation or hospital admission

Arthritis

Epilepsy

Pain

Back problems

Chronic illness

Weight issues

Migraine

Dizzy spells

Depression

Chronic fatigue

Fibromyalgia

Health Details(Required)

Please give details about the condition(s) you selected above

Your Experience(Required)

Have you practiced mindfulness or yoga before?

Yes

Expectations

What are you hoping to gain by attending the classes?

Other difficulties

Have you suffered from any significant trauma or difficulties that would be helpful for the teacher to know about? Please give details.

Hearing/Sight(Required)

Are you hard of hearing or do you have difficulties seeing the screen?

Yes

Other details

Is there anything else you would like to add?

Please call me on 01823 697890 or email info@mindfulnessuk.com, in confidence, if there is anything additional that you feel it would be important for me to know to enable me to support you as best I can during the classes. All the information given will be stored securely and adheres to GDPR.

Declaration(Required)

I declare that I have disclosed all the relevant information regarding my health and well- being.

I have disclosed all relevant information