Nature Nurture
Health Questionnaire

Nature Nurture Retreats

Health Questionnaire

First name

Last name

Phone

Birthday

Do you have any illness or injury that prevents you from safely exercising?*

Yes

Has your doctor or any other health professional said that you should not exercise?*

Yes

Do you feel pain in your chest when you perform physical activity?*

Yes

Do you have high blood pressure?*

Yes

Do you have any joint, bone or muscle injuries/concerns?*

Yes

Do you lose your balance due to dizziness or do you ever lose consciousness?*

Yes

Do you have any dietary requirements, food allergies or other special requirements?*

Yes

If you answered yes to any of the above questions please provide further details. If you are unsure if you are fit to participate in any of Nature Nurture retreats, classes, workshops and activities please contact us or consult a health professional.

Hands on assistance/adjustments may be offered during your class/workshop/retreat. If you would prefer not to receive assistance/adjustments please tick the box or talk to us on the day.

Tell us about your yoga practice/experience

I am new to yoga

I have attended a couple classes but not have a regular practice

I have a regular practice

I declare that the information I have provided is accurate & complete and if anything changes I will inform you.

During my time with Nature Nurture Retreats I will take full responsibility for my own health & safety at all times and will adhere to all health, safety & social regulations.

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Nature Nurture Health Questionnaire

Nature Nurture Retreats

Nature Nurture
Health Questionnaire