Health declaration

Please fill out the following form.

First name

Last name

Age

Email

Have you been hospitalized in the last 12 months?

No

Yes

Are you suffering from a medical condition, illness or injury?

No

Yes

If you answered yes to any of the questions above, please supply additional information, for example, if you are currently taking any medication

Please describe how you feel physically and emotionally. Areas of tension, muscle pain, tightness, injuries, stress, anxiety, depression, etc.

I declare that the info I’ve provided is accurate and complete and that I accept the conditions of service