Health Questionnaire | Parati Wellness

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Parati Yoga & Wellness
Health Questionnaire

Disclaimer: Personal Information may only be used or disclosed for the purpose for which it was collected unless you have otherwise consented, or when it is required or permitted by law. Personal Information will only be retained for the period of time required to fulfill the purpose for which we collected it or as may be required by law.

Participant First Name

Participant Last Name

Phone

Emergency Contact Name

Emergency Contact Phone Number

Check box if this waiver is for a minor under the age of 16 years of age. If checked...parents provide the information below.

Parent Full Name & Phone number

Age of minor

Do any of the following medical conditions apply to you? Please check all that apply * Required

High Blood Pressure

Low Blood Pressure

Arthritis

Diabetes

Heart Problems

Asthma

Depression and/or Anxiety

Eye Problems

Epilepsy

Recent fracture or sprain

Recent surgeries

Back problem or pains

Knee problem or pains

Recent pregnancies

Currently pregnant

Vertigo

Lightheadedness

Any Blood Disorders

Other

Not applicable

If yes to any of the above, please provide a brief description

I am at least 16 years of age and understand it's the participants duty to inform the teacher/school, if there would be changes to my medical history.

I want to stay in the loop, on upcoming events.

I confirm that the information I entered is accurate and true and also certify that I am the parent or legal guardian of any minors listed above.

Your Signature - By typing your name below, you are electronically certifying this health questionnaire is accurate to your knowledge. (If this waiver is for a minor under the age of 16, a parent or guardian must sign below.

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Warmest regards,
The Parati Yoga & Wellness Team

Embrace Self-Love: Your Journey Starts at Parati!

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Parati Yoga & Wellness Health Questionnaire

Embrace Self-Love: Your Journey Starts at Parati!

Parati Yoga & Wellness
Health Questionnaire