Name *

First Name

Last Name

Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Does your emergency contact person know you are participating in this program? *

YES

NO

Are you under the care of a physician for a current or ongoing medical condition? If so, please describe *

YES

NO

Do you wear a Medic-Alert Tag or any other marker of a medical problem? If yes, please describe *

YES

NO

Were you hospitalized in the last two years? If yes, please describe *

YES

NO

Have you ever had a heart attack of any kind, or been told by a doctor that you have high blood pressure, a heart murmur or heart disease? If yes, please describe *

YES

NO

Have you ever had a seizure of any kind? If yes, please describe *

YES

NO

Are you allergic to environmental substances, foods, drugs, insect bites or stings? Have you ever had an anaphylactic (severe allergic) reaction to any of the above? If yes, please describe *

YES

NO

Do you have hemophilia or any other disorder that impairs blood-clotting? If yes, please describe *

YES

NO

Do you have a lung disease or any kind of breathing problem? If yes, please describe *

Yes

No

Do you have any muscle, joint, or bone related disabilities? If yes, please describe *

Yes

No

Do you have a history with migraines or severe headaches? If yes, please describe *

Yes

No

Do you have any kidney disease? If yes, please describe *

Yes

No

If you walked a level mile at an average pace would you get out of breath, have chest or leg pains or develop muscle fatigue?

YES

NO

Do you have documented hypoglycemia or diabetes? If yes, please describe *

YES

NO

Do you have any other chronic or acute condition that, in any way, threatens your health? If yes, please describe *

YES

NO

Are you taking any medication at the present time? If yes, specify each drug, the dose and the reason for taking *

YES

NO

This information is accurate and complete. I agree to cooperate with the Ecology of Awakening guides with full consideration of my health history and health concerns *

YES

Date *

MM

DD

YYYY